17 Oct 23

How Lawyers Advise Physicians on Healthcare Fraud Allegations

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Last Updated on: 28th October 2023, 06:22 pm

How Lawyers Advise Physicians on Healthcare Fraud Allegations

Healthcare fraud is a big issue these days. Lots of doctors get accused of it. But most of them are just trying to help patients and make a living. They don’t wanna break the law. So when doctors get accused of fraud, they need good lawyers to advise them on what to do.

There are a bunch of complicated laws about healthcare fraud. The main ones are the False Claims Act, the Anti-Kickback Statute, the Stark Law, and the Exclusion Statute[1]. These laws make it illegal to overcharge Medicare or Medicaid, take kickbacks, self-refer patients, or commit other fraud.

If a doctor gets accused of violating these laws, they could get fined a ton of money or even go to jail! They could also lose their medical license and get kicked out of Medicare and Medicaid. That would end their career[2].

So doctors gotta be real careful to follow the rules. But the laws are confusing. And sometimes doctors make honest mistakes. That’s why it’s important to have a lawyer if you get accused of fraud.

How Lawyers Investigate Fraud Allegations

The first thing a lawyer will do is investigate the allegations. They’ll look at the evidence and try to figure out what really happened[3].

Some questions they might ask are:

  • What exactly is the doctor accused of doing?
  • Is there proof it was intentional fraud versus an accident?
  • Are the billing codes and medical records accurate?
  • Did the doctor actually perform the services billed?
  • Was anything medically unnecessary or upcoded?

Lawyers have investigators that can help dig into the details. They’ll interview office staff and pull medical charts. This helps them understand the situation.

Possible Defenses for Healthcare Fraud

After investigating, the lawyer will look for defenses to fight the allegations. Some possible defenses include[4]:

  • Lack of intent – If there’s no evidence the doctor purposely tried to defraud anyone, it’s not fraud.
  • Mistake – Doctors are human and make billing mistakes sometimes. That’s not illegal.
  • Bad advice – If the doctor got bad advice from a colleague or staff, they may not be fully responsible.
  • Disagreement over codes – There can be gray areas when picking billing codes that are open to interpretation.
  • Lack of proof – The burden is on the government to prove fraud beyond a reasonable doubt.
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A good lawyer will look for facts that support these defenses. If they can show the doctor acted in good faith, the charges might get dismissed.

Negotiating Settlements of Fraud Allegations

If the evidence of fraud looks bad, the lawyer may try to negotiate a settlement. This avoids a trial and may lead to reduced fines or penalties.

In settlement talks, the lawyer will try to[5]:

  • Get charges dropped or reduced to less serious offenses
  • Minimize fines and repayment amounts
  • Avoid exclusion from Medicare and Medicaid
  • Prevent loss of medical license
  • Reduce chances of criminal prosecution

Settlements often require the doctor to enter a “corporate integrity agreement.” This is a plan to improve compliance and prevent future fraud.

Defending Doctors at Trial

If a case goes to trial, the lawyer’s job is to create reasonable doubt in the jury’s mind. They will[4]:

  • File motions to exclude prejudicial evidence
  • Cross-examine witnesses to undermine their credibility
  • Object to evidence that violates the rules
  • Present experts that support the doctor’s defense
  • Argue the prosecution hasn’t met their burden of proof

In some cases, the lawyer may admit to minor billing errors but argue they were unintentional. Juries are often sympathetic to doctors just trying to help patients.

Avoiding Healthcare Fraud Allegations

The best way for doctors to deal with fraud allegations is to avoid them in the first place. Here are some tips[3]:

  • Have a strong compliance program and follow it
  • Audit billing procedures regularly to catch errors
  • Properly document medical necessity for procedures
  • Use proper coding based on medical records
  • Watch for red flags like high utilization or unusual billing
  • Do regular training on fraud laws for staff
  • Consult lawyers early if issues arise

Following these steps helps minimize fraud risk. But when allegations do happen, an experienced lawyer can be invaluable. They’ll thoroughly investigate the claims and build the strongest defense. This gives doctors the best chance of protecting their career and reputation.

So if you’re a doctor facing fraud allegations, don’t go it alone. Call a lawyer right away. With an expert advisor on your side, you can get through this difficult situation.