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Responding to Credentialing & Licensing Healthcare Fraud Charges

Responding to Credentialing & Licensing Healthcare Fraud Charges

Healthcare professionals face immense pressure and heavy workloads, so mistakes can happen. But if allegations of fraud arise, the legal consequences can be severe. Let’s walk through some basics on responding if you find yourself accused of credentialing, licensing, or wider healthcare fraud.

I know this must be an incredibly stressful situation. But stay hopeful – these charges can be fought, and there are often viable defenses or mitigating factors. Working with an experienced legal team is key. They can fully investigate the allegations, build a defense strategy that fits your situation, and advocate for an appropriate resolution. You don’t have to go through this alone.

Understanding the Allegations

Healthcare fraud laws are complex. Charges could relate to anything from inaccurate billing codes, to misrepresenting credentials or services, to elaborate kickback schemes. The allegations against you outline specific infractions, so analyzing those closely with your attorney is the critical first step.

What exact fraudulent acts do they allege? Are multiple offenses cited? Are the charges civil or criminal? Understanding the scope and nature of the accusations guides how to respond and build your defense.

Common Healthcare Fraud Allegations

Some of the most common allegations against healthcare practitioners include:

  • Medicare/insurance fraud – Billing for services not performed, billing higher codes than appropriate, billing for unnecessary services, etc.
  • Licensing fraud – Falsifying credentials, concealing disciplinary actions, practicing without a valid license or beyond your qualifications.
  • Kickbacks – Accepting bribes or compensation to send patients to a specific healthcare company.
  • Prescription fraud – Illegally distributing medications, self-prescribing, or prescribing without an exam.

The list goes on. But the key is pinpointing exactly what fraudulent acts you’re accused of so your defense stays laser-focused.

Gathering Evidence & Building Your Defense

The best defense is a strong offense backed by evidence. As soon as possible, you’ll want to start gathering anything documenting that you acted properly or at least without intent to defraud. What records can you compile showing legitimate credentials, billing practices, prescriptions, etc?

  • Documentation – Charts, billing records, educational credentials, prescription logs, patient test results, communications, etc. Anything backing up your practices.
  • Expert opinions – Other practitioners who can review records and attest to the medical necessity and appropriateness of treatment plans.
  • Witnesses – Anyone who can speak to your character or verify treatment details and billing processes. Coworkers, assistants, patients themselves.

Don’t overlook simple documentation like appointment calendars, continuing education certificates, and emails. Seemingly minor evidence can be pieced together for a broader defense.

And errors alone don’t necessarily indicate willful fraud. Billing mistakes happen, especially with complex coding protocols. You may have a viable “good faith” defense that you acted without intent to defraud. An attorney can help demonstrate this by compiling evidence you made efforts to bill properly – whether through personnel, technology, or your own continuing education.

Seeking a Favorable Resolution

Once the allegations are understood and the defense evidence gathered, your attorney begins negotiating for the most favorable outcome possible. Their legal knowledge and experience with similar cases is invaluable here.

In criminal matters especially, fighting outright can be risky where loss means harsh penalties. Skilled counsel knows how to strategically approach prosecutors or work through pretrial diversion programs. This shifts focus to restitution and rehabilitation rather than harsh punishment. Civil charges also often end in settlement, which your lawyer can negotiate to limit damage to your credentials, finances, and reputation.

There are almost always multiple ways to resolve these cases. An attorney well-versed in healthcare fraud defenses will pursue paths leading to the best possible outcome for you. Finding the right legal advocate is crucial.

Impact on Licensing & Credentials

One major concern is how allegations or charges, whether proven or not, might impact your professional licensing status or hospital credentials. State boards and healthcare facilities have a duty to investigate misconduct that could endanger patients. So they may take action on licenses/credentials even before criminal or civil proceedings conclude.

Your attorney’s role includes liaising with these bodies to prevent or minimize interruptions to your livelihood. In many cases, negotiating an agreement letting you continue practicing under additional supervision, remedial education, or other conditions is possible. Full license/credential suspension or revocation generally only comes if fraud is proven or patient harm too severe to allow ongoing practice.

So try not to panic if your license or credentials are affected early on. This is often temporary or limited until the charges play out. Your lawyer knows what steps to take, arguments to make, and terms to negotiate so you can continue providing (and earning from) your vital services.

Moving Forward After Resolving Charges

Even if charges are ultimately dismissed or resolved through settlement, the impact on finances, career, and reputation can linger. So before this chapter fully closes, a few final considerations:

  • Financial recovery – Restitution, legal fees, or business disruption may have caused money struggles. Consult a financial advisor to map plans for stabilizing personal and practice finances going forward.
  • Reputation management – Unproven allegations still harm reputations today. SEO experts can help generate new positive content that pushes down reports of allegations in search results over time.
  • Process improvements – No practice is perfect. Assess gaps that may have enabled errors, miscommunications, or process breakdowns. Additional personnel, technology enhancements, or internal controls could help avoid issues resurfacing.

While a difficult season, even resolved allegations ultimately make practices better and stronger. Stay encouraged that this intense challenge will pass, as so many have for other practitioners before you.

In Closing

I hope this overview helps in facing this sensitive and high-stakes situation. Healthcare fraud charges have steep implications, but also viable defenses if the right evidence and advocacy come to bear. Don’t hesitate to retain skilled legal counsel to stand by your side. They have the expertise to carefully investigate allegations, build an appropriate defense, and negotiate the best possible path ahead for your practice and peace of mind. You can get through this difficult season and come out the other side making an even greater difference in patients’ lives.

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