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So your probably sitting there with a Civil Investigative Demand from the Department of Justice about Medicare or Medicaid billing and your entire world is collapsing. Maybe a whistleblower filed a qui tam lawsuit against you that’s been under seal for months. Maybe CMS data analytics flagged your billing patterns as suspicious. Or maybe your just unlucky and got caught in there latest healthcare fraud sweep. Look, we get it. Your ABSOLUTELY TERRIFIED. And you should be! Because Medicare fraud penalties start at $11,000 PER CLAIM plus triple damages!
Let me tell you exactly what this CID means – the government thinks your stealing from Medicare and Medicaid, and there building a case to prove it. A Civil Investigative Demand is DOJ’s most powerful pre-litigation weapon under the False Claims Act. They can demand any document, require written answers under oath, and compel testimony – all without a judge’s approval!
Here’s what’s really happening: there’s probably a sealed whistleblower lawsuit filed against you that you don’t even know about. The government has been investigating you for months or even years in secret. The CID is there way of gathering the final evidence they need to either intervene in the whistleblower case or file there own lawsuit. And trust us, when DOJ intervenes, they win over 95% of the time!
The scope is staggering. There gonna want every billing record, every patient file, every email about billing decisions, every financial record showing payments received. They want to see your relationships with referring physicians, your marketing practices, your medical necessity documentation. Its a complete proctology exam of your entire practice!
Sit down before you read this because the numbers are gonna make you sick. Under the False Claims Act, your facing penalties of $13,946 to $27,894 per false claim PLUS three times the amount the government says it lost.
Let us do some terrifying math for you. Say you billed Medicare for 100 patients a month for 3 years with allegedly improper codes. That’s 3,600 claims. At minimum penalties, that’s over $50 MILLION just in per-claim penalties! Add triple damages on top of that and your looking at complete financial destruction.
But wait, it gets worse! Each line item on a claim can be counted as a seperate false claim. So that single office visit with 5 procedure codes? That’s potentially 5 false claims, not one. We’ve seen solo practitioners hit with $100 million judgments that destroyed there entire life savings, there home, there retirement – everything gone.
Your probably wondering “How did they find me?” Let us tell you the dirty truth about what triggers these investigations.
Whistleblowers are the biggest source – and they get 15% to 30% of whatever the government recovers! That disgruntled employee you fired? That billing company you stopped using? That competitor who lost patients to you? They all have millions of reasons to report you. We’ve seen office managers get $10 million whistleblower awards for reporting there own doctors!
Data analytics is huge too. CMS runs sophisticated algorithms comparing your billing to other providers. Bill more than average for certain codes? Red flag. Have unusual referral patterns? Red flag. High percentage of certain procedures? Red flag. The computers flag you before any human even looks at your claims.
RAC audits, ZPIC investigations, and MAC reviews all feed into fraud referrals. What starts as a routine audit can escalate to criminal investigation faster than you can imagine. Even patient complaints can trigger investigations – one angry patient calling Medicare fraud hotline can destroy your entire practice.
Look, we’re not gonna sugarcoat this – trying to handle a Medicare/Medicaid CID without experienced counsel is like doing brain surgery on yourself. Its technically possible but your gonna die on the operating table.
Here’s what happens when doctors try to go it alone: They produce privileged documents that should have been protected. They make statements that DOJ twists into admissions of fraud. They miss critical deadlines and face obstruction charges. They don’t understand the False Claims Act’s “knowledge” standard and accidentally admit to reckless disregard.
The biggest mistake? Thinking you can explain your way out of it. “But I was just following industry standard!” “Everyone bills this way!” “I relied on my billing company!” None of these excuses work. Under the FCA, reckless disregard or deliberate ignorance is enough for liability. You don’t need intent to defraud – that’s what makes it so dangerous!
If you got a CID, there’s probably a whistleblower (called a “relator”) who filed a qui tam lawsuit against you. These cases are filed under seal, meaning you have no idea who sued you or what they alleged. The seal typically lasts 60 days but gets extended for years while DOJ investigates.
The whistleblower has already given DOJ a roadmap of your supposed fraud. They’ve provided documents, identified witnesses, explained your billing practices. They know your operation from the inside and there highly motivated – they get up to 30% of any recovery! We’ve seen whistleblowers get $50 million awards from single cases.
Here’s what’s especialy unfair – even if the whistleblower was involved in the fraud, they can still collect a reward! We’ve seen billing managers who created fraudulent schemes turn around and report there own employers for massive rewards. Its absolutely DISGUSTING but perfectly legal under the FCA.
YES! And it happens way more than you think. What starts as a civil CID often becomes a criminal investigation. Healthcare fraud carries up to 10 years in federal prison per count. If someone was injured? 20 years. If someone died? Life in prison.
The transition from civil to criminal usualy happens when DOJ finds evidence of intent. Falsified medical records? Criminal. Kickback schemes? Criminal. Lying to investigators? Criminal. Destroying documents after getting the CID? Definately criminal.
We’ve defended respected physicians who went from pillars of there community to federal inmates because they didn’t take CIDs seriously. One client thought his billing issues were just “technical violations” – he’s serving 5 years in federal prison right now. Another client tried to “fix” records after getting the CID – she got 7 years for obstruction.
Ignoring or improperly responding to a Medicare/Medicaid CID is like pouring gasoline on a fire. Here’s what happens:
DOJ immediately files a motion to compel in federal court. The judge WILL order compliance – judges don’t mess around with federal subpoenas. You’ll face contempt charges and daily fines until you comply. DOJ assumes your hiding massive fraud and expands there investigation. Criminal referral becomes almost certain.
But even responding incorrectly causes disasters. Produce documents without proper privilege review? You’ve waived attorney-client privilege forever. Make inconsistent statements? That’s a false statement charge. Miss something in your production? That’s obstruction. We’ve seen practices hand DOJ everything they needed for conviction just through sloppy CID responses.
Buckle up because your in for a long, expensive ride. Medicare/Medicaid fraud investigations typically take 2-4 years from CID to resolution. During this entire time, your practice is under a microscope, your reputation is in tatters, and your bleeding money in legal fees.
The timeline usualy looks like this: Initial CID response (30-60 days), DOJ review and follow-up demands (6-12 months), witness interviews and depositions (6-12 months), settlement negotiations or litigation (12-24 months). And that’s if everything goes smoothly!
During this time, your practice suffers tremendously. Banks won’t lend to you. Partners leave. Employees quit. Patients find new doctors. Referral sources dry up. We’ve seen thriving practices become ghost towns within months of a CID becoming public.
Your facing three possible outcomes, and honestly, none of them are good:
Settlement is most common – you pay millions in penalties and damages, enter a Corporate Integrity Agreement that monitors you for years, and possibly face exclusion from Medicare/Medicaid. Its financially devastating but keeps you out of prison.
Fighting it at trial is risky – DOJ wins over 95% of intervened cases. If you lose, penalties are maximum, criminal referral is likely, and bankruptcy is almost certain. But sometimes its your only option if DOJ’s demands are unreasonable.
Declination is rare but possible – DOJ decides not to pursue the case. This only happens when there’s clearly no fraud or the whistleblower’s allegations are completely baseless. Don’t count on it.
Time is NOT on your side with a Medicare/Medicaid CID. Every day you wait, DOJ is building there case. There interviewing witnesses who might say things that hurt you. There analyzing data that makes you look worse. There coordinating with criminal prosecutors.
Early intervention is critical. We can sometimes shape the investigation’s direction before DOJ locks into a theory. We can present exculpatory evidence before they make charging decisions. We can negotiate scope limitations before they demand everything. But once DOJ forms there opinions, changing there minds is nearly impossible.
The fastest way to make things worse? Trying to “clean up” your billing or documentation after receiving the CID. DOJ has already captured your data – they’ll know if you change anything. We had a client who tried to add medical necessity documentation after getting a CID. That turned a $2 million civil case into a criminal prosecution for obstruction.
Here’s another nightmare – Medicare fraud investigations rarely happen in isolation. Your facing multiple proceedings simultaneously:
The qui tam lawsuit continues even during DOJ’s investigation. State Medicaid Fraud Control Units might open there own investigations. State medical boards might threaten your license. Private insurance companies might audit and recoup payments. Hospitals might suspend your privileges. Other whistleblowers might file copycat lawsuits.
Each proceeding has different rules, different penalties, different defenses. What helps in one might hurt in another. We’ve seen doctors successfully defend the federal case only to lose there medical license to the state board. Its a minefield that requires careful coordination.
We’re not your typical healthcare lawyers who just know regulations. We’re criminal defense attorneys who specialize in keeping healthcare providers out of federal prison. We know the False Claims Act inside and out. We understand Medicare billing, coding, and documentation requirements. We speak both medical and legal language fluently.
More importantly, we know how to fight DOJ’s Healthcare Fraud Unit. We know there tactics, there pressure points, there settlement authorities. We know which AUSAs are reasonable and which are zealots. We’ve taken these cases to trial and won when other firms would have surrendered.
The difference experience makes is massive. We know how to present medical judgment issues that DOJ doesn’t understand. We can distinguish between billing errors and fraud. We can negotiate Corporate Integrity Agreements that don’t destroy your practice. Most importantly, we can keep civil cases from becoming criminal prosecutions.
Call us RIGHT NOW at 212-300-5196
The government is building there case against you TODAY!
Free consultation – Payment plans available – We know healthcare fraud defense!
Don’t wait another minute! Every hour you delay responding properly to this CID is another hour DOJ is ahead of you. There building there case, interviewing witnesses, analyzing data. You need someone fighting back immediately!
Remember – the government has unlimited resources, teams of attorneys, and a 95% win rate when they intervene. The whistleblower has millions of reasons to bury you. You need someone equally motivated and experienced protecting you. Call us NOW before this civil investigation becomes criminal charges that destroy your life!
Very diligent, organized associates; got my case dismissed. Hard working attorneys who can put up with your anxiousness. I was accused of robbing a gemstone dealer. Definitely A law group that lays out all possible options and best alternative routes. Recommended for sure.
- ROBIN, GUN CHARGES ROBIN
NJ CRIMINAL DEFENSE ATTORNEYS