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Defending Against Healthcare Fraud Charges in Audits & Raids

Defending Against Healthcare Fraud Charges in Audits & Raids

Healthcare fraud refers to an act committed with the intent to defraud a health plan, such as an insurance company or a government-funded healthcare program. Healthcare fraud encompasses various fraudulent activities related to healthcare services and benefits, typically involving the submission of false or misleading information to obtain unauthorized payments or benefits.Healthcare fraud charges can be complex, carrying severe penalties and long-lasting consequences for those accused. When facing such allegations, having a knowledgeable and skilled healthcare fraud defense attorney is crucial to protect your interests and navigate the legal system.This article provides an overview of defending against healthcare fraud charges stemming from audits and raids. It covers key aspects like:

• Common healthcare fraud charges
• Conducting internal audits
• Best practices when raided
• Potential defenses
• Sentencing and penalties

Understanding Healthcare Fraud Charges

Some of the most common forms of healthcare fraud charges include:

• Billing for services not rendered: Charging for medical services, tests, or procedures that were never actually provided.
• Upcoding: Billing for more expensive services than were actually rendered to receive higher reimbursements.
• Kickbacks: Receiving money or gifts to refer patients to a particular healthcare provider or service.
• Misrepresenting non-covered treatments: Falsely indicating that a non-covered service is medically necessary to obtain reimbursement.
• Falsifying patient diagnoses: Changing diagnosis codes to justify tests, additional services, or equipment.

The penalties for healthcare fraud charges vary based on the amount of money involved and specific offenses. However, many healthcare fraud crimes are felonies carrying substantial penalties like steep fines and years in prison.

Conducting Internal Healthcare Fraud Audits

Given the complexity of healthcare regulations and billing procedures, honest mistakes can occur that technically constitute fraud.Conducting regular internal audits can help identify and address such issues before they trigger larger investigations. It also demonstrates a commitment to compliance.Some best practices for internal healthcare fraud audits include:

• Reviewing billing and coding processes to ensure accuracy and compliance
• Comparing reimbursement rates to benchmarks to check for upcoding
• Validating patient diagnosis codes and medical necessity of treatments
• Cross-checking provider credentials and licenses
• Assessing kickback risks associated with referrals
• Sampling previous claims submissions to check for errors
• Staying current with evolving regulations and guidance

Documenting a robust internal audit process can be invaluable in defending against healthcare fraud charges. It shows that any issues were mistakes rather than intentional attempts to defraud.

Best Practices When Raided

Despite best efforts, your practice may still face external audits or raids by investigators. Raids typically involve authorities entering your facilities to collect records and data through search warrants.It’s crucial to involve your legal counsel at the first sign of a raid or records seizure. But some initial best practices include:

• Remain calm and cooperative: Avoid interfering with investigators or destroying records.
• Don’t answer questions without counsel: Investigators may try soliciting information that could aid prosecutors. Avoid discussing the investigation or making any statements without your attorney present.
• Carefully review warrants: Verify warrants are signed by a judge and address specific suspicions. Alert authorities to privileged information.
• Take detailed notes: Document all interactions, lists of seized records, statements made by investigators, etc.
• Contact counsel immediately: Brief them on the situation so they can begin assessing risks and building a defense strategy centered around your rights.

While raids can seem intimidating, having an experienced legal team in your corner makes a major difference.

Potential Defenses Against Healthcare Fraud Charges

Some potential defenses that skilled healthcare fraud attorneys may employ include:

Lack of Intent

For most fraud charges, prosecutors must establish you knowingly and willfully attempted to defraud health plans or obtain unauthorized funds. Evidence showing honest mistakes or a general lack of intent can defeat charges.

Coercion

If employees or others conducted fraudulent activities under threats or pressure from superiors, it may relieve lower-level staff of liability. However, upper management would likely still face prosecution.

Statute of Limitations

Depending on specific charges, statutes of limitations on fraudulent activities may have expired, preventing prosecution. But limits vary widely based on state laws and nature of offenses.

Constitutional Violations

Your attorney can challenge the admissibility of evidence, statements, or warrants if investigators violated rights against unlawful search & seizure, self-incrimination, due process, and more.The viability of defenses depends heavily on the specific circumstances and evidence in each case. An experienced attorney will assess the strengths and weaknesses to build the strongest defense.

Sentencing and Penalties

If convicted of healthcare fraud, penalties vary based on state laws and the degree of fraud charges. Some examples of potential sentencing under New York statutes include:

• 5th Degree (up to $3,000 in a year): Misdemeanor with up to 1 year in prison
• 4th Degree (over $3,000 in a year): Felony with up to 4 years in prison
• 3rd Degree (over $10,000 in a year): Felony with up to 7 years in prison
• 2nd Degree (over $50,000 in a year): Felony with 5 to 15 years in prison
• 1st Degree (over $1 million in a year): Felony with up to 25 years in prison

Fines, probation, restitution payments, and forfeiture of assets often supplement incarceration sentences. Prosecutors may also pursue related charges like larceny, scheme to defraud, or money laundering that carry additional penalties.Convictions can also trigger professional discipline actions against licenses and exclusion from federally-funded healthcare programs.

The Value of an Experienced Healthcare Fraud Defense Attorney

Facing healthcare fraud charges can completely disrupt your life and career. The complexity of these cases combined with the severe criminal penalties demonstrate the immense value of engaging a top healthcare fraud defense attorney.Whether preparing for a raid, currently under investigation, or already facing charges, a skilled attorney intimately familiar with healthcare regulations and fraud prosecution tactics could make all the difference. They know how to build the strongest defense by challenging flawed warrants, unreliable evidence, or violations of your rights.If you require assistance defending against healthcare fraud charges in New York, reach out for a free case assessment from an experienced fraud defense attorney that understands the intricacies of these complex regulatory issues. The right legal guidance can help mitigate risks and protect your future.