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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.

Christine Twomey
Christine Twomey
2024-03-21
Just had my Divorce case settled 2 months ago after having a horrible experience with another firm. I couldn’t be happier with Claire Banks and Elizabeth Garvey with their outstanding professionalism in doing so with Spodek Law Group. Any time I needed questions answered they were always prompt in doing so with all my uncertainties after 30 yrs of marriage.I feel from the bottom of my heart you will NOT be disappointed with either one. Thanks a million.
Brendan huisman
Brendan huisman
2024-03-18
Alex Zhik contacted me almost immediately when I reached out to Spodek for a consultation and was able to effectively communicate the path forward/consequences of my legal issue. I immediately agreed to hire Alex for his services and did not regret my choice. He was able to cover my case in court (with 1 day notice) and not only was he able to push my case down, he carefully negotiated a dismissal of the charge altogether. I highly recommend Spodek, and more specifically, Alex Zhik for all of your legal issues. Thanks guys!
Guerline Menard
Guerline Menard
2024-03-18
Thanks again Spodek law firm, particularly Esq Claire Banks who stood right there with us up to the finish line. Attached photos taken right outside of the court building and the smile on our faces represented victory, a breath of fresh air and satisfaction. We are very happy that this is over and we can move on with our lives. Thanks Spodek law 🙏🏼🙏🏼🙏🏼🙏🏼🙌🏼❤️
Keisha Parris
Keisha Parris
2024-03-15
Believe every single review here about Alex Z!! From our initial consultation, it was evident that Alex possessed a profound understanding of criminal law and a fierce dedication to his clients rights. Throughout the entirety of my case, Alex exhibited unparalleled professionalism and unwavering commitment. What sets Alex apart is not only his legal expertise but also his genuine compassion for his clients. He took the time to thoroughly explain my case, alleviating any concerns I had along the way. His exact words were “I’m not worried about it”. His unwavering support and guidance were invaluable throughout the entire process. I am immensely grateful for Alex's exceptional legal representation and wholeheartedly recommend his services to anyone in need of a skilled criminal defense attorney. Alex Z is not just a lawyer; he is a beacon of hope for those navigating the complexities of the legal system. If you find yourself in need of a dedicated and competent legal advocate, look no further than Alex Z.
Taïko Beauty
Taïko Beauty
2024-03-15
I don’t know where to start, I can write a novel about this firm, but one thing I will say is that having my best interest was their main priority since the beginning of my case which was back in Winter 2019. Miss Claire Banks, one of the best Attorneys in the firm represented me very well and was very professional, respectful, and truthful. Not once did she leave me in the dark, in fact she presented all options and routes that could possibly be considered for my case and she reinsured me that no matter what I decided to do, her and the team will have my back and that’s exactly what happened. Not only will I be liberated from this case, also, I will enjoy my freedom and continue to be a mother to my first born son and will have no restrictions with accomplishing my goals in life. Now that’s what I call victory!! I thank the Lord, My mother, Claire, and the Spodek team for standing by me and fighting with me. Words can’t describe how grateful I am to have the opportunity to work with this team. I’m very satisfied, very pleased with their performance, their hard work, and their diligence. Thank you team!
Anthony Williams
Anthony Williams
2024-03-12
Hey, how you guys doing? Good afternoon my name is Anthony Williams I just want to give a great shout out to the team of. Spodek law group. It is such a honor to use them and to use their assistance through this whole case from start to finish. They did everything that they said they was gonna do and if it ever comes down to it, if I ever have to use them again, hands-down they will be the first law office at the top of my list, thank you guys so much. It was a pleasure having you guys by my side so if you guys ever need them, do not hesitate to pick up the phone and give them a call.
Loveth Okpedo
Loveth Okpedo
2024-03-12
Very professional, very transparent, over all a great experience
Bee L
Bee L
2024-02-28
Amazing experience with Spodek! Very professional lawyers who take your case seriously. They treated me with respect, were always available, and answered any and all questions. They were able to help me very successfully and removed a huge stress. Highly recommend.
divesh patel
divesh patel
2024-02-24
I can't recommend Alex Zhik and Spodek Law Firm highly enough for their exceptional legal representation and personal mentorship. From the moment I engaged their services in October 2022, Alex took the time to understand my case thoroughly and provided guidance every step of the way. Alex's dedication to my case went above and beyond my expectations. His expertise, attention to detail, and commitment to achieving the best possible outcome were evident throughout the entire process. He took the time to mentor me, ensuring I understood the legal complexities involved to make informed decisions. Alex is the kind of guy you would want to have a beer with and has made a meaningful impact on me. I also want to acknowledge Todd Spodek, the leader of the firm, who played a crucial role in my case. His leadership and support bolstered the efforts of Alex, and his involvement highlighted the firm's commitment to excellence. Thanks to Alex Zhik and Todd Spodek, I achieved the outcome I desired, and I am incredibly grateful for their professionalism, expertise, and genuine care. If you're in need of legal representation, look no further than this outstanding team.

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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