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What to Do if You’re Under Investigation for Healthcare Fraud

What to Do if You’re Under Investigation for Healthcare Fraud

Getting that dreaded letter informing you that you’re under investigation for healthcare fraud can be terrifying. Your mind races with questions and concerns about your reputation, your practice or business, your employees, your family – not to mention the possibility of huge fines or even jail time.Take a deep breath. Although the situation is serious, panicking won’t help. Let’s walk through this step-by-step so you understand what’s happening, what you need to do next, and how to protect yourself.

The Background

First, understand that healthcare fraud investigations are on the rise. This is due to a few key factors:

  • More people have health insurance now – Since the Affordable Care Act, more Americans have health insurance. That means more claims filed, more opportunities for mistakes or fraud.
  • Technology makes it easier to detect fraud – Investigators are using sophisticated data analytics to spot anomalies and patterns that may indicate fraud.
  • The opioid epidemic has increased focus on healthcare fraud – With opioid abuse on the rise, regulators are closely watching prescribing patterns for controlled substances.
  • Penalties for healthcare fraud have increased – The Affordable Care Act increased fines and jail time for those found guilty of healthcare fraud.

So if you receive that dreaded letter, know that you’re not alone. But also understand that the stakes are high if fraud is proven, so you need to take it very seriously.

If You Get a Target Letter

If you receive a letter informing you that you are under investigation for healthcare fraud, it’s called a “target letter.” This means prosecutors have reason to believe you may have committed fraud, but they have not filed formal charges yet.Target letters will come from the Department of Justice (DOJ), the FBI, the Drug Enforcement Agency (DEA), or your state’s Medicaid Fraud Control Unit. Often, several agencies are investigating together in a joint task force.Do not panic. You’re not required to do anything yet. But you should immediately contact a lawyer experienced in healthcare fraud defense. Choosing the right legal counsel is crucial. This complex specialty requires knowledge of healthcare regulations and laws as well as experience negotiating with federal prosecutors.Be careful who you tell about the investigation. Do not discuss it with employees or colleagues without your attorney present. Prosecutors often try to get targets to make incriminating statements early in the process.

The Investigation Process

Healthcare fraud investigations typically follow this general process, although each case is unique:1. Prosecutors issue subpoenas to collect evidence.They will subpoena medical records, billing records, bank statements, phone records, etc. You must comply, but always consult your attorney first about how to respond. Never provide more than what is legally required.2. Auditors review records looking for improper claims.The audit examines your documentation – medical charts, billing records, etc. – to identify any claims that were improperly billed to Medicare, Medicaid, or private insurers.3. Investigators interview you, employees, and sometimes patients.Answer questions truthfully, but do not speculate or volunteer information. Always have your attorney present. Say you don’t recall if you’re unsure.4. Prosecutors decide whether to pursue criminal charges or a civil settlement.Your attorney will negotiate aggressively to prevent or minimize any charges.5. If charged, you can fight the case in court or settle.Settlements often involve repaying overpayments, fines, practice monitoring, and exclusion from federal programs.6. If found guilty of criminal fraud, you face fines, prison time, and exclusion.Prosecutors typically offer plea bargains to avoid trial. An experienced attorney is key to getting the best deal.This process can take many months or even years before reaching resolution. It is a marathon, not a sprint. Manage stress and anxiety through exercise, meditation, talking to friends and family, or professional counseling. Don’t go through it alone.

If Investigators Show Up Unannounced

If federal agents appear unannounced at your home or office to interview you, remain professional and courteous, but do not consent to an interview without your attorney present.Tell them you want to cooperate, but need to have your lawyer with you first. Ask for their contact information so your attorney can reach out to schedule an interview.Instruct employees not to answer questions without an attorney present. Federal agents may use pressure tactics or make threats, but employees have the right to consult a lawyer before talking.If agents have a warrant, do not interfere with their search. Tell them you do not consent to any search, then step aside and let them do their job. Take notes of what they photograph or seize as evidence. Having an attorney present during the search is extremely helpful.

Common Types of Healthcare Fraud

While each case is unique, most healthcare fraud allegations fall into a few general categories:Medicare/Medicaid fraud – Billing for services not provided, duplicate billing, billing for unnecessary services, etc.Improper coding – “Upcoding” to bill for more expensive services than provided or “unbundling” billing codes.Kickbacks – Accepting money or gifts to refer patients to a certain healthcare provider.Misrepresenting services – Falsely billing non-covered services as medically necessary covered services.Prescription fraud – Billing for drugs that were not dispensed, selling prescriptions, etc.Identity theft – Using a patient or provider’s information without authorization to submit fraudulent claims.Self-referrals – Referring patients to your own business for profit.Tax fraud – Not reporting income from fraud schemes.There are also many types of fraud committed by patients, such as selling prescriptions, doctor shopping, and using someone else’s insurance.

Christine Twomey
Christine Twomey
2024-03-21
Just had my Divorce case settled 2 months ago after having a horrible experience with another firm. I couldn’t be happier with Claire Banks and Elizabeth Garvey with their outstanding professionalism in doing so with Spodek Law Group. Any time I needed questions answered they were always prompt in doing so with all my uncertainties after 30 yrs of marriage.I feel from the bottom of my heart you will NOT be disappointed with either one. Thanks a million.
Brendan huisman
Brendan huisman
2024-03-18
Alex Zhik contacted me almost immediately when I reached out to Spodek for a consultation and was able to effectively communicate the path forward/consequences of my legal issue. I immediately agreed to hire Alex for his services and did not regret my choice. He was able to cover my case in court (with 1 day notice) and not only was he able to push my case down, he carefully negotiated a dismissal of the charge altogether. I highly recommend Spodek, and more specifically, Alex Zhik for all of your legal issues. Thanks guys!
Guerline Menard
Guerline Menard
2024-03-18
Thanks again Spodek law firm, particularly Esq Claire Banks who stood right there with us up to the finish line. Attached photos taken right outside of the court building and the smile on our faces represented victory, a breath of fresh air and satisfaction. We are very happy that this is over and we can move on with our lives. Thanks Spodek law 🙏🏼🙏🏼🙏🏼🙏🏼🙌🏼❤️
Keisha Parris
Keisha Parris
2024-03-15
Believe every single review here about Alex Z!! From our initial consultation, it was evident that Alex possessed a profound understanding of criminal law and a fierce dedication to his clients rights. Throughout the entirety of my case, Alex exhibited unparalleled professionalism and unwavering commitment. What sets Alex apart is not only his legal expertise but also his genuine compassion for his clients. He took the time to thoroughly explain my case, alleviating any concerns I had along the way. His exact words were “I’m not worried about it”. His unwavering support and guidance were invaluable throughout the entire process. I am immensely grateful for Alex's exceptional legal representation and wholeheartedly recommend his services to anyone in need of a skilled criminal defense attorney. Alex Z is not just a lawyer; he is a beacon of hope for those navigating the complexities of the legal system. If you find yourself in need of a dedicated and competent legal advocate, look no further than Alex Z.
Taïko Beauty
Taïko Beauty
2024-03-15
I don’t know where to start, I can write a novel about this firm, but one thing I will say is that having my best interest was their main priority since the beginning of my case which was back in Winter 2019. Miss Claire Banks, one of the best Attorneys in the firm represented me very well and was very professional, respectful, and truthful. Not once did she leave me in the dark, in fact she presented all options and routes that could possibly be considered for my case and she reinsured me that no matter what I decided to do, her and the team will have my back and that’s exactly what happened. Not only will I be liberated from this case, also, I will enjoy my freedom and continue to be a mother to my first born son and will have no restrictions with accomplishing my goals in life. Now that’s what I call victory!! I thank the Lord, My mother, Claire, and the Spodek team for standing by me and fighting with me. Words can’t describe how grateful I am to have the opportunity to work with this team. I’m very satisfied, very pleased with their performance, their hard work, and their diligence. Thank you team!
Anthony Williams
Anthony Williams
2024-03-12
Hey, how you guys doing? Good afternoon my name is Anthony Williams I just want to give a great shout out to the team of. Spodek law group. It is such a honor to use them and to use their assistance through this whole case from start to finish. They did everything that they said they was gonna do and if it ever comes down to it, if I ever have to use them again, hands-down they will be the first law office at the top of my list, thank you guys so much. It was a pleasure having you guys by my side so if you guys ever need them, do not hesitate to pick up the phone and give them a call.
Loveth Okpedo
Loveth Okpedo
2024-03-12
Very professional, very transparent, over all a great experience
Bee L
Bee L
2024-02-28
Amazing experience with Spodek! Very professional lawyers who take your case seriously. They treated me with respect, were always available, and answered any and all questions. They were able to help me very successfully and removed a huge stress. Highly recommend.
divesh patel
divesh patel
2024-02-24
I can't recommend Alex Zhik and Spodek Law Firm highly enough for their exceptional legal representation and personal mentorship. From the moment I engaged their services in October 2022, Alex took the time to understand my case thoroughly and provided guidance every step of the way. Alex's dedication to my case went above and beyond my expectations. His expertise, attention to detail, and commitment to achieving the best possible outcome were evident throughout the entire process. He took the time to mentor me, ensuring I understood the legal complexities involved to make informed decisions. Alex is the kind of guy you would want to have a beer with and has made a meaningful impact on me. I also want to acknowledge Todd Spodek, the leader of the firm, who played a crucial role in my case. His leadership and support bolstered the efforts of Alex, and his involvement highlighted the firm's commitment to excellence. Thanks to Alex Zhik and Todd Spodek, I achieved the outcome I desired, and I am incredibly grateful for their professionalism, expertise, and genuine care. If you're in need of legal representation, look no further than this outstanding team.

Key Defense Strategies

An experienced attorney will deploy many tactics to build your defense case:

  • Attack sloppy audits – Many audits have significant flaws. Your legal team will scrutinize the audit evidence.
  • Highlight honest mistakes – Unintentional billing errors happen and don’t always constitute willful fraud.
  • Question use of sampling – Extrapolating fraud from a small sample often overstates the scope.
  • Dispute overpayments – You have the right to appeal audit findings and overpayment amounts.
  • Challenge witness credibility – Witness or co-conspirator testimony can often be called into question.
  • Demonstrate good faith – Jurors relate to honest mistakes and efforts to follow complex rules.
  • Show lack of intent – Prosecutors must prove you knowingly and willfully committed fraud.
  • Highlight compliance efforts – Showing you tried to comply with regulations helps undermine allegations.
  • Appeal to prosecutorial discretion – Your attorney will work to convince prosecutors not to pursue minor or questionable cases.

The bottom line is you have strong defenses and experienced counsel can get charges dismissed or greatly reduced in many cases. So don’t panic and don’t go it alone.

If You’re Found Liable

If ultimately found guilty of healthcare fraud, the penalties can be severe depending on the extent of the fraud proven:

  • Civil monetary penalties – These can include having to repay 2-3x the amount of any overpayments, plus fines of $5,000-$50,000 per claim.
  • Criminal fines – For criminal fraud convictions, individuals can face fines up to $100,000 per fraudulent act.
  • Jail time – Healthcare fraud may be punished by up to 10 years in prison for each count. Harsher sentences apply if patients were endangered.
  • Exclusion from federal programs – Those convicted of healthcare fraud are prohibited from participating in Medicare and Medicaid.
  • Loss of licensure – Your professional license can be suspended or revoked if found guilty of fraud.
  • Debarment – You may be prohibited from doing business with any government healthcare program.
  • Asset forfeiture – The government can seize personal assets obtained through fraud schemes.
  • Reputational harm – Fraud convictions destroy careers and professional reputations.

The stakes are high, which is why having an experienced legal team in your corner from the start is so critical.

How to Prevent Healthcare Fraud

The best protection is putting measures in place to prevent fraud from ever occurring:

  • Conduct regular audits – Routinely audit a sample of your own billing and medical records to catch any problems.
  • Implement a compliance program – Create formal policies and procedures to promote compliance with billing and documentation rules.
  • Train your staff – Educate all employees on proper billing, coding, documentation, etc.
  • Use billing software with auditing features – Choose technology that flags errors and includes auditing tools.
  • Stay up to date on regulations – Sign up for email updates from Medicare or join associations to stay current.
  • Correct errors immediately – If you discover you’ve been overpaid by a federal program, disclose and return the overpayment promptly.
  • Seeks legal counsel when needed – Have an experienced healthcare attorney review new ventures like joint ventures or employment agreements.
  • Ask questions if unsure – Don’t ever guess about proper billing, coding, etc. Speak up if you need clarification.

Healthcare regulations are incredibly complex. Even with robust compliance efforts, innocent mistakes can happen. But implementing these best practices will help you avoid or more quickly detect inadvertent errors and reduce your fraud risk.

Conclusion

Allegations of healthcare fraud should always be taken very seriously given the potential consequences. If you receive a target letter or visit from federal agents, contact experienced legal counsel immediately. An attorney well-versed in this niche area of law will advise you on responding to investigators and build the strongest case possible in your defense. Don’t panic, but don’t go it alone. With the right legal strategy, many healthcare fraud investigations can be resolved favorably.

References

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