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Responding to Healthcare Fraud Charges from Whistleblowers

Responding to Healthcare Fraud Charges from Whistleblowers

Getting that dreaded letter informing you of an investigation into healthcare fraud can be terrifying. As a medical professional, the last thing you want is to be accused of fraudulent billing practices or coding errors. Even if you believe you’ve done nothing wrong, whistleblower complaints can trigger expensive legal battles that put your reputation and career on the line.

So what should you do if faced with allegations of healthcare fraud? Don’t panic. There are steps you can take to mount an effective defense, minimize fallout, and protect yourself both legally and professionally. This article provides an overview of whistleblower claims, how to respond initially, building your defense strategy, and proactive ways providers can limit fraud liability.

Understanding Whistleblower Lawsuits

The False Claims Act (FCA) allows private citizens to file fraud lawsuits on behalf of the government against entities they believe are defrauding Medicare or Medicaid programs. These “qui tam” suits entitle whistleblowers to receive 15-30% of recovered funds if successful.

Over the last decade, amendments expanding the FCA’s scope have triggered more healthcare fraud cases. Common allegations include:

  • Billing for services never performed
  • Upcoding claims to receive higher reimbursements
  • Providing and billing for unnecessary medical care
  • Paying kickbacks for patient referrals

When whistleblowers file complaints under seal, the Department of Justice (DOJ) investigates claims before determining if they’ll intervene. Over 90% of cases result in settlement, but if you choose to fight allegations it can involve lengthy litigation.

Penalties for FCA violations are severe, including treble damages plus $11,000 – $22,000 per false claim. With thousands of line items per bill submission, potential fines can skyrocket into millions.

Responding to Notice of a Claim

If you receive notice you’re under investigation, don’t panic. Here are initial steps to take:

Get organized

Pull billing records, patient files, and other documentation tied to allegations. You’ll need these to build your defense.

Consult experienced legal counsel

Retaining false claims act attorneys early is critical for mounting an aggressive defense. Lawyers can interface with investigators on your behalf.

Conduct internal investigation

Review records related to complaint allegations and investigate billing and coding processes. If errors or oversights occurred, document findings for corrective actions.

Avoid obstructing investigators

Be cooperative with DOJ lawyers and investigators. Obstruction or destruction of records can result in criminal charges.

Begin building your defense strategy

With counsel, determine what evidence refutes claims and supports your billing and coding were accurate.

Don’t admit liability

Even if errors did occur, don’t admit fault or liability. Doing so can weaken your negotiating stance for settlement.

Building Your Defense Strategy

Constructing a strong defense requires analyzing whistleblower allegations to find weaknesses that undermine their merits. Here are proven strategies FCA attorneys use:

Disprove allegations of falsity

If billing documentation, medical records, and coding substantiate services were performed and claims valid, you can fight accusations. But records must clearly align with billing.

Challenge materiality arguments

If coding errors or oversights occurred, assess if they’re material FCA violations or minor administrative mistakes unlikely to influence payment decisions. Immaterial errors may not constitute fraud.

Dispute allegations of knowledge

Under the FCA, providers must have known billing claims were false. Your track record of compliance and actions taken upon discovering errors can rebut notions you intended to defraud Medicare.

Highlight relator credibility issues

If whistleblowers have professional or personal grudges, a lack of direct knowledge about billing activities, or a financial incentive driving claims, it damages their trustworthiness.

Negotiate settlement

If allegations have merit, seeking settlement early on can minimize damages. Admitting errors doesn’t necessarily mean admitting liability.

How Providers Can Limit Fraud Liability

While you can’t eliminate whistleblower risk entirely, proactive steps make you a less likely FCA target:

Perform regular audits

Internal and external audits help catch innocent coding errors before they become patterns that raise suspicions.

Implement compliance training

Annual staff training on proper billing and coding procedures shows good faith efforts to avoid fraud.

Enhance documentation practices

Detailed medical record documentation that clearly supports diagnoses and procedures on claims protects you in case of allegations.

Stay updated on billing and coding

As requirements evolve, inadequate coder training can result in non-fraudulent billing mistakes.

Create open channels for worker feedback

Encouraging staff to share compliance concerns allows you to self-report issues and make corrections before they become FCA complaints.

Consult regulatory guidance

Seeking advice from Medicare contractors helps clarify gray areas that could trigger billing errors.

Consider self-disclosure

Discovering innocent billing irregularities and voluntarily refunding overpayments can motivate settlements favorable to providers.The prospect of defending healthcare fraud charges is daunting for any medical professional. But understanding whistleblower claims, responding appropriately from the outset, and building an aggressive defense with experienced legal counsel significantly improves your chances of a favorable outcome. And by taking proactive fraud prevention measures, you can reduce the likelihood disgruntled employees or opportunistic relators target your organization in the first place.

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