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Medicare Fraud Defense Lawyers

June 19, 2019

There are numerous ways that you could commit Medicare fraud, some that aren’t intentional. If you’ve received allegations about this type of activity that could have taken place in your medical office, it’s important to seek the assistance of an attorney who can look at the evidence in place before putting together a defense. If there is not enough evidence to substantiate the claims against you, then a possible defense could be that you were unaware that any kind of Medicare fraud was taking place in the office or that it wasn’t taking place in an intentional fashion. However, if you know that you have committed this kind of fraud, then you need to work with your attorney to present why it occurred and how you can make changes so that it doesn’t happen again. You also need to work with your attorney to put together a proper defense to try to keep your medical license so that you can continue practicing in the medical field.

Before meeting with an attorney, you need to understand what could be considered as Medicare fraud. One of the easiest ways to commit Medicare fraud is by billing for medical services that aren’t needed or that aren’t performed. Home healthcare services are also included in this type of fraud as you could file for services that are provided when they aren’t Pharmacy fraud could also occur as Medicare payments could be accepted for prescriptions that aren’t filled or that are filled for a generic brand while Medicare is charged for the name brand. Upcoding is a common way to commit this type of fraud as well. This often means that more codes are billed for instead of only the codes associated with a diagnosis or service provided.

When working with your attorney, you’ll often have to provide copies of financial records that relate to Medicare payments. There’s usually a time frame that has been investigated, which usually means that you’re only going to need to submit documents for that time frame to your attorney. Try to submit witness statements and other details from healthcare professionals in the office who know that Medicare fraud has not taken place. If there are workers in the office or hospital who have committed this type of fraud without your knowledge, then you need to take the proper actions against those workers while also submitting the proper documents associated with the workers involved. These documents could be used in the defense that your attorney puts together to try to get your sentence minimized or to get the charges against you dropped.

The attorney you hire needs to be one who understands healthcare and who is able to write the proper letters and statements on your behalf whether the details involve defending your actions or submitting details that indicate you didn’t commit fraud. It’s important to begin putting together a defense as soon as you receive details from the state or a federal agency in order to possibly keep your license throughout the process.

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Establishing Fraud

The subject of Medicare Fraud is a very complex one and can necessitate the aid of an attorney who is well versed in this particular area. For the purpose of halting acts of Medicare fraud against the government, a whistleblower might file a civil lawsuit under the False Claims Act. Any individual or entity that has witnessed fraudulent actions against federal programs or contracts can stand as a whistleblower. The kind of lawsuit that a whistleblower may initiate is known as a qui tam. 

This is how a qui tam lawsuit works. The claimant is filing suit on behalf of the government. They are referred to as a “relator”. Essentially, the relator is assisting the government in eliminating waste, fraud and abuse by stepping forward. Oftentimes, The relator is entitled to a financial reward in a successful qui tam lawsuit. If you have encountered fraud, it’s a good idea to consult an attorney to see if you are eligible to initiate a qui tam lawsuit.

Picking the right qui tam attorney from the start is the key to  a successful outcome. Here are some factors to take into account when choosing a qui tam attorney:

  • The attorney’s experience in qui tam and other cases involving Medicare Fraud
  • What resources the attorney has at his or her disposal
  • The attorney’s xperience and familiarity with the kinds of whistleblower cases the government customarily prioritizes and pursues
  • The attorney’s level of understanding of the risks involved with filing these suits

An Explanation of Qui Tam 

The Federal False Claims Act is a federal law that imposes liability on persons and entities that defraud governmental Medicare and Medicaid programs. Also known simply as the False Claims Act, this is the government’s primary ammunition in combating fraud. As evidence, over 70% of all False Claim lawsuits were brought by whistleblowers as of 2012. From 1987 to 2013, $27.2 billion dollars were recovered in qui tam cases initiated by whistleblowers. More than 700 False Claims actions were brought by whistleblowers in 2014 alone.

Under the False Claims Act, any Medicare payment associated with illegal activity or noncompliance with federal regulations could be classed as Medicare Fraud. Indeed, there are numerous diverse kinds of Medicare Fraud.  One common factor among them is that the fraud has attempted to collect money from a government payor under false pretenses. Here are some practices that may constitute fraud (this list is by no means exhaustive):

  • Billing Medicare for a good or service that is not medically necessary
  • Billing Medicare in a fashion that fails to  accurately represent the goods or services that were actually provided
  • Billing Medicare for goods or services that were never rendered at all
  • Failure to comply with FDA regulations
  • Violations of the Anti-Kickback Statute
  • Violations of the Stark Law
  • Improper or noncompliant documentation of personal information

The way a whistleblower reports some fraudulent practice they have encountered to the government is under the qui tam provision to the False Claims Act. In qui tam lawsuits, the government sometimes finds just cause to intervene and join the lawsuit. If the government is successful in recovering damages, the whistleblower is entitled to up to 25% of what the government recovers.

Things to consider when deciding whether to pursue a qui tam case as a whistleblower: 

  • How likely is it that the defendant will be liable for a substantial judgment
  • What liability under the False Claims Act is the defendant guilty of
  • What harm was caused to the government
  • Will you be able to pursue the lawsuit as a whistleblower
  • What risks are involved with filing suit

It’s imperative for whistleblowers to be aware that the False Claims Act prohibits:

  • Knowingly bringing forth, or causing to be brought forth a false claim for payment or approval
  • Knowingly producing, utilizing, or causing to be produced or untilized, a false record or statement material to a false or fraudulent claim
  • Colluding to commit any violation of the False Claims Act
  • The certification of receipt of property on a document without any verification of the veracity of the information therein
  • Falsifying the certification of the type or amount of property to be employed by the Government
  • Knowingly purchasing Government property from an unauthorized officer of the Government and
  • Knowingly producing, utilizing, or causing to be produced or utilized a false record to avoid or bring down the amount of an obligation to pay or transmit property to the Government

For these prohibited acts, the False Claims Act imposes liability for treble damages and a civil penalty ranging from $5,000 to $10,000 per claim for anyone who knowingly submits or causes the submission of a false or fraudulent claim (treble damages are a multiple of, and not an addition to, actual damages). Nonetheless, certain claims are also not actionable. These concerns should be addressed with an attorney.

How Our Attorneys Can Assist You

Spodek Law Group attorneys possess an impressive depth of knowledge and experience with qui tam lawsuits. They are customarily filed under seal in federal district court in accordance with the Federal Rules of Civil Procedure. Complications could arise that have the potential to harm a person pursuing a claim without counsel.



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