What to Do if You’re Being Investigated for Healthcare Claims Fraud

What to Do if You’re Being Investigated for Healthcare Claims Fraud

Getting that letter in the mail saying you’re being investigated for healthcare claims fraud can be terrifying. Your first instinct might be to panic. But try to stay calm. An investigation doesn’t necessarily mean you did something wrong. Here’s what you need to know and do if this happens to you.

Don’t Ignore It

You’ll probably want to pretend that investigation letter doesn’t exist. But ignoring it won’t make it go away. The agency investigating you – whether it’s the FBI, Department of Justice, or an insurance company – will keep looking into the situation with or without your cooperation. So ignoring the letter will likely just make things worse in the long run.

Get Legal Help

One of the first things you should do is get a lawyer. A healthcare fraud investigation can turn into a criminal case. So you need someone on your side who understands the law and can advocate for you. Don’t try going it alone. The stakes are too high here.

Look for an attorney who specializes in healthcare fraud defense. They’ll be familiar with the legal issues and defense strategies. Be sure to ask about their experience with cases like yours. The more similar cases they’ve handled, the better.

Review the Allegations

Your lawyer will want to thoroughly review the investigation letter and evidence against you. Make sure you understand what specific allegations are being made. Are you being accused of billing for services that weren’t provided? Upcharging for care? Kickbacks? Something else? The details matter.

Go through each allegation point-by-point with your attorney. Explain the situation from your perspective. Provide any documentation you have that could refute the accusations. Make sure your lawyer has all the facts.

Gather Additional Records

Your lawyer will likely ask you to gather additional documentation that could be relevant to your defense. This might include things like:

• Patient medical records
• Billing and payment records
• Emails and correspondence related to the allegations
• Financial and accounting records from your practice
• Records of services provided to patients

Be as thorough as possible in compiling relevant records. They could help prove your innocence. Or at least cast doubt on the accusations against you.

Cooperate with the Investigation

While you don’t have to say anything that might incriminate you, in general it’s wise to cooperate with investigators. If you refuse to provide documents or sit for an interview, it can look like you have something to hide.

Your lawyer can help you decide which documents to turn over and how to respond in an interview. With your attorney present, be truthful when answering questions. But don’t speculate or volunteer information that isn’t requested.

Consider Settlement Options

Your attorney may advise trying to settle the case instead of going to trial. Settlements often involve paying a fine and agreeing to increased oversight going forward. You’ll likely have to admit some responsibility, even if there are extenuating circumstances.

Settlements allow you to avoid criminal prosecution. But they can still have serious consequences like:

• Fines and repayment of funds
• Exclusion from Medicare/Medicaid programs
• Loss of medical license

So weigh your options carefully when deciding whether to settle. You want to resolve the case, but also protect your livelihood.

Don’t Retaliate Against Whistleblowers

If a current or former employee reported you, don’t retaliate. Whistleblower laws prohibit punishing people for reporting possible violations. Retaliation could lead to additional legal action against you.

Avoid Social Media Posts

It’s natural to want to vent on social media when you’re dealing with stressful situations. But avoid posting anything about your case online. Comments could potentially be used against you. Even posts set to “friends only” can still end up being seen by investigators.

Seek Emotional Support if Needed

Being under investigation for healthcare fraud is stressful. Don’t be afraid to lean on loved ones for emotional support and comfort. You may also find it helpful to talk to a professional counselor. Having an outlet to process your feelings can help you cope.

Start Preparing Your Defense

Your lawyer will determine the best defense strategy based on the specifics of your case. But some common defenses in fraud cases include:

• You acted in good faith and had no intent to defraud
• There was no falsification or misrepresentation
• An employee acted alone without your knowledge
• There was a misunderstanding about complex regulations

Your attorney may also look for procedural problems with how the investigation was conducted. Or try to show that the allegations aren’t supported by the evidence. Coming up with an effective defense takes time. So start the process as soon as possible.

Explore Your Grievance Options

If you believe the investigation itself was unfounded or conducted improperly, you may have grievance options. Your lawyer can help you file complaints with the appropriate oversight organizations. This won’t make the investigation go away. But it could help resolve some issues in your favor.

Expect the Process to Take Awhile

Healthcare fraud investigations are complex. So expect the whole process to take months or even years before it’s resolved. The waiting can be frustrating and disrupting to your life and career. But try to be patient and let your lawyer navigate each step. Rushing things will likely just cause more problems in the end.

Don’t Lose Hope

Being accused of healthcare fraud feels devastating. The financial and professional consequences can be severe even if you’re innocent. It’s normal to feel scared about the outcome. But don’t assume the worst. Focus on presenting your defense and know that the truth still matters. With an experienced legal team on your side, many cases do get resolved favorably in the end.

Sources

Healthcare Fraud – Justice Department
Healthcare Fraud Investigations – Lawyers.com
What to Do When Accused of Healthcare Fraud – NOLO
CMS Fraud & Abuse Resources