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What is involved in a healthcare fraud investigation?

It’s no secret that the medical industry is highly regulated and scrutinized. Because healthcare fraud costs the government and taxpayers billions of dollars every year, the federal government as well as the Texas State Attorney General’s Office and the Texas Department of Insurance devote immense amounts of resources to uncover fraud and prosecute those accused. Individuals and organizations that are accused of committing healthcare fraud, either directly or indirectly, can be liable for civil and/or criminal penalties. In this blog, we will address some issues that are considered Medicaid and Medicare fraud, how an investigation may start, your options in responding to an investigation, potential penalties and a brief overview of some of the federal laws that govern state and federal healthcare fraud.

Common Examples of Medicaid and Medicare fraud include:

  • Upcoding: the practice of using a billing code that results in a higher reimbursement rate than the level of service justifies.
  • Unbundling codes: The practice of using two or more Current Procedural Terminology (CPT) billing codes instead of one inclusive code.
  • Double-billing Medicare or Medicaid and a private company for the same treatment. Double billing also occurs when a provider attempts to charge for the same service by billing using an individual code and again as part of a bundled set of tests.
  • Billing Medicare for appointments the patient failed to keep
  • Billing for services not furnished, supplies not provided, or both, including falsifying records to show delivery of such items
  • Paying for referrals of Federal health care program beneficiaries
  • Improper business arrangements designed to induce referrals
  • Accepting or providing anything of value for referrals for Medicare or Medicaid services
  • Business relationships where compensation is not set at a fair market value or charging excessively for services or supplies
  • Certifying patients for unneeded services
  • Failure to make timely repayment when an overpayment is identified (60-Day rule)

The investigation: How a healthcare fraud case starts:

  • An analyst uncovers a claim pattern that he or she regards as suspicious; or
  • An insider or whistleblower files a report to authorities (Centers for Medicare and Medicaid Services (CMS)
  • A disgruntled patient files a report or compliant

Receiving a letter from a fraud investigator – what next?

The Inspector General employs a host of investigators and auditors who are exceptional at spotting inconsistencies and unusual patterns in purchasing and billing. The investigator may ask you to provide certain documents or request to interview you and/or request to interview your employees. If federal and state investigators come knocking on your door for an interview, chances are these agencies have already invested significant time and resources investigating your case, and therefore might already have solid evidence against you or your practice. Please take note that anything you say to the investigator may be used to find you guilty of fraud, even if you are told you “are not the target of the investigation”.

Medicare and Medicaid fraud investigations can have serious consequences, including criminal charges, disenrollment from Medicare and Medicaid, fines, and sanctions against you or your practice. The earlier you contact us, the sooner we will begin investigating and preparing your case. Call 713-783-3110 or contact us online.

I’m being investigated! What are my rights?

  • You have the right to bring a lawyer to the interview.
  • You have the right to consult with a lawyer
  • You have the right to remain silent.

Possible Medicaid and Medicare fraud penalties and consequences:

  • Suspension or loss of a medical license
  • Monetary fines or penalties
  • Restitution orders
  • Recoupment of payments
  • Removal from the Medicare billing program
  • Disqualification or exclusion from receiving Medicaid benefits and/or exclusion from participating in Medicaid as a healthcare provider
  • Criminal prosecution and a possible incarceration
  • Civil judgments and liens on any real property you own

Strategic representation in any healthcare fraud matter:

The regulations governing Medicaid and Medicare are highly complex. Surprisingly, a majority of incidents are legitimate misunderstandings or billing errors which result in allegations of Medicare or Medicaid fraud. At Hendershot Cannon Martin & Hisey P.C., we understand that a violation could not only mean legal penalties but could also jeopardize your medical license, certifications and your career. We will represent you at every step of a civil fraud investigation -beginning before allegations arise. We can advise you on the creation, implementation, and maintenance of compliance plans designed to prevent and resolve problems before they become investigations. If state or federal government agencies do conduct investigations, we will prepare a strong and aggressive defense. We are well versed and experienced in handling civil investigative demands, subpoenas, interviews, document production, hearings and trial.

We regularly advise defendants on the most complex health care regulations affecting providers in Texas, including:

Are you under investigation? Let’s discuss your case. Call 713-783-3110 or contact us online.

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