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What to Do if You’re Being Investigated for Healthcare Billing Fraud

What to Do if You’re Being Investigated for Healthcare Billing Fraud

So you got a letter saying your being looked at for possible healthcare billing fraud. That really sucks. I know your probably freaking out wondering what happens next. Take a deep breath. This don’t necessarily mean your guilty of anything. Lots of investigations end with no charges filed. This article will walk you through how to handle a fraud investigation the right way.

Understanding Healthcare Billing Fraud

First up – what exactly is healthcare billing fraud? It’s when someone intentionally lies or misleads to get more money from Medicare, Medicaid, or private health plans. Some examples include:

  • Billing for services that weren’t provided
  • Billing for more expensive services than actually done
  • Using a patient’s info to bill for services for someone else
  • Billing multiple payers for the same service

Most docs and medical providers follow the rules. But fraud still happens. And when caught, you may face criminal charges or civil lawsuits to recover money.

Who Investigates Healthcare Fraud

Several agencies can investigate fraud allegations like:

  • DOJ – Runs Medicare Fraud Strike Forces with FBI, investigates criminal cases.
  • OIG – Inspector General’s office investigates Medicare fraud.
  • State Medicaid Fraud Control Units – Investigate Medicaid fraud for states.
  • Private insurers – Have their own fraud investigation units.

These investigators have power to subpoena records, interview witnesses, get search warrants, and make arrests.

If You Get a Subpoena

A subpoena means they want records from you. Don’t ignore it – that can lead to obstruction charges. Hire a lawyer immediately to help respond. They’ll ensure you meet the deadline and protect any privileged info.

Gather the records requested and provide to your attorney to review and turn over. Don’t alter or destroy any subpoenaed records – that’s illegal.

Christine Twomey
Christine Twomey
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Guerline Menard
Guerline Menard
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If Investigators Want to Interview You

Investigators may ask to interview you as part of the probe. Politely decline and refer them to your lawyer. NEVER speak without your attorney present – anything you say can be used against you.

Your lawyer will prepare you for the interview and attend to make sure your rights are protected.

Building Your Defense

While the investigation unfolds, start building your defense in case charges come. Gather records like:

  • Medical records backing up services billed
  • Timesheets and schedules proving you were working
  • Emails and documents refuting allegations
  • Records of compliance training

Basically gather anything showing you billed properly. Also write a timeline from your view. Your attorney can compare it to the investigators’ timeline.

If Charges Are Filed

If formal fraud charges get filed, your lawyer will walk you through the process and build a defense strategy. This may include:

  • Seeking dismissal of defective charges
  • Negotiating a plea bargain
  • Going to trial

Don’t lose hope – charges sometimes get dismissed pre-trial. And even if convicted, your lawyer can argue for leniency.

Cooperating with Investigators

Your lawyer may advise cooperating with the investigation, like through a proffer session. This involves sitting down with investigators informally and sharing what you know. Statements you make can’t be used directly against you.

Cooperation can lead to lesser charges or even immunity. But run it by your attorney first – don’t go it alone.

Avoiding Retaliation

It’s illegal for anyone to retaliate against you for cooperating with investigators. Report any harassment, discrimination, or other retaliation to your lawyer immediately.

Takeaways if Facing an Investigation

Here’s a quick summary of what to do if your under investigation for healthcare billing fraud:

  • Get a lawyer immediately
  • Don’t ignore subpoenas
  • Don’t talk to investigators without your lawyer
  • Gather evidence of your innocence
  • Consider cooperating through your attorney
  • Report any retaliation

And stay positive! Many probes end with no action taken. But if charges come, fight them with your lawyer’s help. Don’t go through it alone.


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