Lawyers Explain How to Prevent Healthcare Fraud Convictions
Contents
Preventing Healthcare Fraud Convictions: A Guide for Lawyers
Healthcare fraud is a serious issue that costs taxpayers billions of dollars each year. As lawyers, we have an obligation to advise our clients on how to stay compliant with complex healthcare regulations. We also must defend them vigorously if they face accusations of fraud.This article provides practical tips for lawyers on helping clients prevent fraud convictions. I discuss common schemes, penalties, and defenses. My goal is to increase awareness so lawyers can better serve clients in the healthcare industry.
Understanding Healthcare Fraud
Healthcare fraud refers to intentionally deceiving Medicare, Medicaid, or private insurers to unlawfully obtain money. Common schemes include:
- Billing for services never performed
- Billing for unnecessary medical procedures
- Accepting kickbacks for patient referrals
- Misrepresenting diagnoses to justify expensive tests
- Waiving patient copays and overbilling insurers
The penalties for healthcare fraud are severe. Providers can face huge fines, exclusion from federal programs, even decades in prison. With so much at stake, it’s critical for lawyers to advise clients on compliance.
Avoiding Allegations of Fraud
The best defense is a good offense. I recommend lawyers counsel clients early on fraud prevention, before issues arise. Here are some proactive steps:Carefully Document Medical NecessityThe key to legally billing federal programs is proving medical necessity. Providers should thoroughly document why they ordered each test and procedure. Records must demonstrate how services specifically relate to the patient’s condition and treatment plan.Audit Charts FrequentlyConduct periodic audits of patient medical charts. Verify that tests ordered match the diagnosis codes submitted for payment. This helps correct innocent mistakes that could appear fraudulent.Screen Business Partners ThoroughlyChoose referral sources carefully. Scrutinize medical equipment suppliers and anyone else you do business with. Avoid partners displaying questionable billing patterns or under investigation.Train Staff on ComplianceEducate all personnel on proper coding, billing, and documentation. Emphasize the dire consequences of fraud. Encourage them to ask questions if uncertain about claims.Seek Legal Advice on IncentivesFinancial relationships in healthcare are highly regulated. Consult an attorney before entering any compensation deal tied to referrals, services billed, etc. Avoid illegal kickbacks disguising as legitimate incentives.Conduct Internal InvestigationsIf staff discover potential compliance issues, launch an internal review immediately. Determine exactly what occurred and how to fix deficiencies. Voluntarily disclosing problems can avert government intervention.
Defending Against Fraud Charges
Despite best efforts, some providers still end up facing fraud allegations. Possible triggers include disgruntled employees reporting them or statistical analysis revealing abnormal billing patterns.If clients receive a subpoena from auditors or criminal investigators, advise them not to panic. There are viable defenses even against inaccurate accusations. Smart lawyers realize the government lacks resources to build strong cases against every target.Here are proven legal strategies for fighting healthcare fraud accusations:Leverage Billing ComplexitiesThe rules around medical necessity, coding, and reimbursement are highly complex. There are often multiple reasonable interpretations. Skilled attorneys identify technicalities supporting the client’s billing decisions.Challenge Sufficiency of EvidenceProsecutors must prove each element of fraud beyond reasonable doubt. Scrutinize their theories, documents, calculations, and assumptions. Many cases fall apart due to evidentiary holes once subjected to rigorous cross-examination.Raise Affirmative DefensesThere are legitimate explanations for conduct that appears illegal on the surface. For instance, certain financial relationships with referral sources meet safe harbor exceptions. Present facts justifying the client’s behavior under governing laws and regulations.Negotiate Favorable SettlementsConvincing authorities to drop or reduce charges is usually better than risking trial. This involves extensive back-and-forth discussion. Seasoned lawyers skillfully negotiate satisfactory compromises for clients facing fraud accusations.Explore Alternatives to Criminal PleasIf settlement talks reach an impasse, all is not lost. Diversion programs allow defendants to avoid convictions through paying restitution plus fines and completing probation. Skilled counsel can sometimes persuade prosecutors to agree to these extraordinary case resolutions.
Conclusion
Lawyers serve a vital role in combating healthcare fraud. We must educate clients on prevention and vigorously defend them if accused. My hope is that this article provided helpful suggestions for fulfilling our professional responsibilities regarding this critical issue. By working together, we can reduce fraud and protect patients.
Sources
https://www.texasattorneygeneral.gov/consumer-protection/health-care/health-care-fraud-and-abuse
https://federal-lawyer.com/texas/healthcare-fraud/medicare/
https://federal-lawyer.com/texas/healthcare-fraud/