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Fighting Allegations of Fraudulent Healthcare Treatment Claims

Fighting Allegations of Fraudulent Healthcare Treatment Claims

Dealing with accusations of healthcare fraud can be stressful for medical professionals. But with the right approach, you may be able to get the charges dismissed or at least reduced. This article covers some key defenses and strategies I’ve seen work for clients in the past.

Understanding Why You’re Being Investigated

First, get very clear on why you’re being investigated in the first place. Common triggers for fraud inquiries include:

  • Abnormally high billing volumes or reimbursement amounts compared to peers
  • Patient or whistleblower complaints about unnecessary/excessive treatments
  • Coding or billing errors that look suspicious
  • Association with others accused of fraud

While an investigation doesn’t mean you actually committed fraud, it does warrant taking things seriously.

Assembling Your Defense Strategy

Now it’s time to start building your defense. I’d recommend:

  • Gathering as much documentation as possible – patient records, communications, coding references, anything showing your honest intentions and due diligence. This paper trail will be crucial.
  • Consulting with a legal team – having experienced healthcare fraud defense attorneys on your side can make a huge difference. They can help craft the right arguments and strategy for your unique situation.
  • Conducting an internal audit – do a deep dive into your records and billing processes to identify any potential issues or process gaps. Self-disclosure shows good faith and that you take compliance seriously.

Key Defenses to Consider

There are a few common defenses my clients have used to fight healthcare fraud charges:

Lack of Intent

To be found guilty, prosecutors must prove you knowingly and willfully committed fraud. If billing issues stemmed from innocent mistakes, clerical errors, lack of training, or misunderstanding of complex coding rules, then you may be able to argue lack of intent. Having detailed documentation and audit trails helps demonstrate due diligence.

Medical Necessity

You can also argue the treatments in question were medically necessary given the patient’s condition and symptoms. Supplying detailed patient records, expert testimonials, and clinical guidelines can help prove appropriateness of care.

Statute of Limitations

There may be time limits on how far back prosecutors can reach in assessing penalties and fines. Checking statute details in your state can reveal cases barred from moving forward.

Procedural Issues

Investigations that violate processes or your rights could have charges dismissed on procedural grounds – whether it’s lack of probable cause for warrants, illegal searches, failure to read rights, denial of counsel access, and more.

Attempting Settlement

If your case does go to court and carries risk of conviction, your legal team may suggest attempting settlement first. This involves negotiating an agreement to pay back a portion of funds in exchange for avoiding further penalties or program exclusion. Settlements can be complex with many variables at play, so having an experienced attorney to guide negotiations is extremely valuable.

The key is being proactive from the start – quickly retaining counsel, launching your own audit, collecting exonerating materials, and crafting arguments around common defenses. With the right evidence and legal tactics, even severe allegations can potentially be defeated. Stay confident and keep fighting!

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