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How Lawyers Investigate Physician Healthcare Fraud Cases

How Lawyers Investigate Physician Healthcare Fraud Cases

Healthcare fraud committed by doctors and other medical professionals is, like, a huge problem that costs taxpayers and insurance companies tons of money every year. I mean we’re talking billions of dollars here, which is pretty crazy when you think about it. Anyways, lawyers play an important role in investigating and prosecuting these complex cases to try and recover some of those losses. Here’s a quick rundown of how they might go about it:

Understanding the Allegations

First things first, the lawyer’s gotta understand what exactly the doctor is being accused of. Common types of healthcare fraud include:

  • Billing for services that weren’t performed
  • Billing for unnecessary tests or procedures
  • Upcoding – billing for more expensive services than were actually provided
  • Kickbacks for patient referrals
  • Prescribing medications for non-medical reasons

So the lawyer will want to get all the specifics about what the doctor allegedly did, when they did it, how much money was involved, etc. This gives them a roadmap for where to start digging.

Reviewing Medical Records

A key piece of evidence is going to be the patient medical records. The lawyer will want to get copies of any records related to the alleged fraudulent billing and start scrutinizing them. They’ll look for things like:

  • Services billed that aren’t documented in the records
  • Diagnosis codes that don’t match the patient’s condition
  • Treatment that doesn’t follow standard medical practice
  • Unnecessary referrals and lab tests

Medical records can be like a foreign language to most lawyers, so they often hire consultants with medical expertise to review them too. But the records can reveal a lot about whether the billing matches the care provided.

Interviewing Witnesses

To get the full story, the lawyer will also want to interview people involved, including:

  • Patients who received the alleged improper treatment
  • Office staff who handled the billing
  • Other doctors familiar with the defendant’s practice
  • Whistleblowers who reported the fraud

These interviews help piece together how the scheme worked and identify weaknesses in the doctor’s defense. Lawyers will look for consistencies and inconsistencies in the witnesses’ accounts. Sworn statements from credible witnesses can be powerful evidence.

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Reviewing Billing Records

Lawyers dig into the doctor’s billing records to analyze patterns and identify red flags like:

  • Billing for an unusually high number of expensive procedures
  • Billing for procedures very different from peers
  • Billing for procedures the doctor isn’t qualified to perform
  • Billing for procedures that are medically impossible (e.g. more than 24 hrs in a day)

They use data analysis to detect anomalies and outliers that could indicate fraud. Billing specialists help interpret complex billing codes and data.

Following the Money

Financial forensics can uncover where fraudulent funds were transferred and how they were used. Lawyers will subpoena bank records, look for suspicious activity, review tax returns, and try to trace the money trail. If funds were used for lavish vacations or real estate, it can demonstrate illegal activity occurred. They’ll also check if any kickbacks were paid out.

Putting Together a Case

Once the lawyer has gathered documents, records, witness statements, and financial analyses, they piece it all together to build their legal case against the doctor. They identify the most damning evidence and draw connections between records, timelines, testimony, and financials to corroborate the allegations. The goal is to construct an ironclad case that proves healthcare fraud beyond a reasonable doubt, though the doctor’s lawyers will look for holes to exploit.

Attempting Settlement

Before going to trial, the lawyer typically tries negotiating a settlement to recover losses and avoid courtroom costs. Doctors may agree to repay funds and accept disciplinary actions in exchange for avoiding criminal prosecution or trial. Settlements can be complex but are often the fastest path to resolving these cases.

Going to Trial

If no settlement is reached, the lawyer takes the case to trial. They present evidence and witness testimony to a judge or jury, aiming to prove intent to defraud. The doctor’s defense lawyers will try to dismiss evidence and raise reasonable doubt. Healthcare fraud trials can get highly technical and complex very quickly with all the medical details involved. Convincing a jury of guilt beyond a reasonable doubt is challenging. But successful convictions send a strong message and help recover stolen funds.

Sentencing and Appeals

If found guilty, the doctor will face sentencing based on the financial losses and severity of the fraud. Punishments may include fines, restitution, probation, or even prison time. The doctor can appeal the verdict and sentence, starting a lengthy appeals process. Lawyers on both sides continue battling it out through appeals until a final resolution is reached.

Recovery of Funds

A major goal of these cases is recouping losses from the fraud. Fines and restitution may be ordered at sentencing. The government can seize assets using forfeiture laws. They’ll recapture any available funds from the doctor’s personal and business accounts. Lawyers also try negotiating larger settlements during appeals to maximize recoveries without further courtroom costs.

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