17 Oct 23

Responding to Healthcare Fraud Allegations: What Lawyers Advise Clients

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Last Updated on: 28th October 2023, 02:32 pm

Responding to Healthcare Fraud Allegations: What Lawyers Advise Clients

Don’t Panic – Get Experienced Legal Counsel

The first thing any lawyer will advise is – don’t panic! While the allegations may seem scary, you have rights that can protect you. The best thing to do is get experienced legal counsel on your side right away.

“These types of cases can get highly complex, with regulations that are constantly changing,” explains defense attorney John Smith. “Having a lawyer who specializes in healthcare law is crucial.”

Your attorney can help analyze the allegations, explain your rights, and start building the strongest defense. They can also interface with investigators on your behalf. This prevents you from accidentally saying something that could hurt your case.

Carefully Review the Allegations

The next step is to thoroughly review the allegations and make sure you understand what regulators believe happened. This includes getting copies of any documentation, like medical records or billing claims.

“You want to know the exact violations you’re accused of, as well as the scope and timeframe,” says healthcare defense lawyer Jane Doe. “Even minor details could make a difference in building your defense.”

Your lawyer can help identify any inconsistencies or erroneous assumptions in the allegations. For instance, a coding error could be mistaken as deliberate fraud.

Gather and Preserve Relevant Records

Your lawyer will advise gathering and preserving any records that could help prove your innocence. This includes financial and medical documents, emails, or other correspondence.

“We’ll want to see the ‘paper trail’ showing exactly what services were provided and billed for,” Doe explains. “If records contradict the allegations, it’s powerful evidence for the defense.”

Your attorney can help identify what records will be most relevant. They’ll also make sure records are preserved correctly to avoid spoliation allegations.

Conduct an Internal Investigation

An internal investigation is often the next step. This involves thoroughly reviewing billing and medical practices to identify any problem areas.

“We need to understand if controls failed or if there are rogue employees involved,” says Smith. “Conducting a robust internal investigation shows regulators you take the allegations seriously.”

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Your lawyer can manage the investigation process, including interviewing employees. They’ll ensure it’s done in a way that doesn’t compromise your defense.

Don’t Destroy or Alter Any Records

It’s absolutely crucial not to destroy or alter any records relevant to the allegations. Doing so can lead to serious obstruction of justice charges.

“Clients sometimes think shredding records will help their case – it actually does the opposite,” warns Smith. “Your lawyer will advise fully preserving and cooperating.”

Be sure to follow your attorney’s instructions about preserving records. Don’t throw anything away or delete files without their approval.

Craft the Strongest Possible Defense

Your lawyer will help build the strongest defense to the allegations. Common strategies include:

  • Showing the allegations are factually incorrect or based on incomplete information
  • Proving you had adequate controls and compliance programs in place
  • Demonstrating the violations were accidental or due to a misunderstanding
  • Arguing the rules or regulations are unclear
  • Claiming a subordinate acted alone without your knowledge

The right defense depends on the specific circumstances of your case. Your attorney will advise the best options.

Consider Self-Disclosure

If internal investigation reveals actual violations, your lawyer may advise self-disclosing them to authorities. Doing so can result in lesser penalties versus waiting for investigators to find problems first.

“Coming forward shows regulators you’re serious about compliance,” says Doe. “We can present self-disclosure in the most favorable light.”

However, your lawyer will need to strategically determine when self-disclosure is beneficial versus asserting your defenses.

Negotiate Fines, Penalties or a Settlement

Rather than go to trial, your lawyer will likely negotiate an agreement with regulators to settle allegations. This can minimize penalties like fines, program exclusion, or losing licenses.

“We’ll work to get investigators to see your side and demonstrate your good faith efforts,” explains Smith. “Even if some penalties are warranted, we can often mitigate them.”

Having an experienced healthcare attorney gives you the best shot at negotiating a favorable settlement.

Implement Corrective Action

As part of settlement negotiations, regulators will want to see you implement corrective actions like:

  • Enhanced employee training and compliance programs
  • Changes to billing and coding practices
  • Increased internal audits and controls
  • Updated policies and procedures

Undertaking meaningful corrective actions shows regulators you’re committed to avoiding problems in the future.