Challenging Healthcare Fraud Charges Due to Compliance Issues

Healthcare fraud charges can seem scary and overwhelming. As a healthcare provider, you may feel confused about how you ended up under investigation when you were just trying to care for your patients. This article will walk you through some of the common compliance issues that can lead to fraud charges, as well as potential defenses you can use to fight the charges.

Why Me? Understanding How You Got Here

There’s no sugarcoating it – the government cracks down hard on healthcare fraud these days. In 2018 alone, over $3 trillion was spent on healthcare in the U.S. And where there’s that much money flowing, there’s inevitably going to be some fraud happening[1].

The government has a whole Healthcare Fraud Prevention and Enforcement Action Team (HEAT) dedicated to sniffing out fraud. And once they open an investigation on you, they dig through every little detail with a fine-toothed comb looking for anything suspicious. Even little mistakes can raise red flags if they think you’re trying to game the system.

So how’d you get caught up in this mess? Well, while some folks actually set out to intentionally defraud Medicare and Medicaid, others simply run into issues trying to navigate the complex tangle of healthcare regulations. Just some of the common compliance pitfalls that can land you in hot water include:

• Upcoding services (billing for more complex/expensive services than provided)
• Billing for services not provided
• Falsifying diagnoses to justify tests or procedures
• Sloppy record-keeping practices
• Unqualified/unlicensed staff providing services
• Violations of self-referral/Anti-Kickback rules

When the government sees coding/billing issues or trends that seem suspicious, you may end up facing an audit or fraud investigation even if you had no ill intentions. But don’t panic – having a qualified legal team in your corner is key to navigating these choppy waters.

Fighting Back Against the Charges

Once you’ve been accused of healthcare fraud, the fight is on to protect your medical license, avoid fines or prison time, and salvage your reputation. As scary as this feels, there are several avenues you can pursue to challenge the charges:

Compliance Program Defense

• If you had a compliance program in place and were making reasonable efforts to comply with regulations, point this out! Simply having a program shows you took steps to avoid fraud.
• Discuss how you train staff on compliance, audit coding/billing, etc. This helps defeat claims you “knowingly and willfully” defrauded Medicare.

Medical Necessity Defense

• For upcoding/unbundling allegations, show documentation proving the billed services were medically needed. Thorough chart notes are key here.
• Get independent expert reviews to validate your medical decision making if necessary.

Statute of Limitations Defense

• There’s a 5-6 year limit on how long after alleged fraud the government can charge you. If too much time has passed, the charges could get tossed.

Reliance on Coding/Billing Expert Defense

• Did you rely on a professional coder or biller? Shift some blame there. Show you tried to do things properly.

Cooperation and Self-Reporting

• Be proactive in the investigation, provide requested records, and consider self-disclosing issues. This shows you’re trying to resolve matters, not hide anything.

Avoiding Future Issues

If you successfully beat the charges (or have to settle), it’s critical to fix any glaring compliance gaps that got you in trouble in the first place. Here are some steps to help avoid repeat issues down the road:

Implement a Compliance Program

Having formal policies and controls in place is your first line of defense if questions arise down the road. Work with experienced healthcare legal counsel to build an appropriate customized program.

Conduct Internal Audits

Regularly audit your coding, billing, documentation, licenses, and other risk areas to identify and address problems. External audits can also help provide an unbiased assessment.

Train Staff Extensively

Ongoing education and compliance training is essential – for clinical staff and office/billing personnel alike. Stress the consequences of non-compliance.

Carefully Select Vendors

If relying on outside entities for coding, billing, electronic records, etc. thoroughly vet them to ensure no compliance red flags. Review their work often.

Seek Legal Counsel When Needed

Have an experienced healthcare attorney available for consultation on risk areas, documentation, business arrangements, or other gray compliance areas. An ounce of prevention is invaluable if issues eventually do occur!

We’ll Get Through This Together

Dealing with healthcare fraud charges can be all-consuming, devastating your finances, mental health, and reputation. But with an experienced legal team guiding you, it is possible to successfully challenge the allegations or mitigate the fallout. Don’t go through this alone – help is out there!

With some adjustments to improve compliance, most physicians can get back to simply caring for their patients. And isn’t that what medicine is truly all about? We know this is just a bump in the road for you too. It may take time to recover, but you’ve got this!