Investigation of Fraud or Abuse

Investigations2018-10-24T19:16:38+00:00

Health Care Fraud and Abuse Defense

It is said that as much as 10% of Medicare’s total budget is lost to fraud, abuse, waste, and improper payments. Losses attributed to fraud and abuse are estimated to be over a billion dollars annually. Examples of the types of issues included in this figure are

  • Billing and/or coding errors;
  • Billing for medically unnecessary items (services, equipment, or supplies);
  • Billing for care, supplies, or equipment not provided;
  • Falsifying patient records;
  • Self-referrals;
  • Kickbacks, rebates, or bribes; and
  • Fraudulent home health or hospice certifications.

Allegations of fraud and abuse are now commonly drawn from over-payment determinations, as well as utilization statistics. Whatever your provider type is, payors are comparing statistical billing patterns to yours. These reviews can determine patterns of upcoding, unbundling and other improper billing practices. Occasionally a provider may have a patient base that requires more complex or a higher level of care, but in general each specialty has been statistically examined.

Should the federal or state governments consider a billing pattern to be excessive, be prepared for an investigation. Possible remedies available to investigators include immediate payment suspension, records requests and/or records seizure.

Fraud and Abuse Lawshhs oig - Investigations

Per the Office of Inspector General for the U.S. Department of Health & Human Services, the five more important Federal fraud and abuse laws that apply to physicians are:

  • False Claims Act (FCA)
  • Anti-Kickback Statute (AKS)
  • Physician Self-Referral Law (Stark Law)
  • Exclusion Authorities
  • Civil Monetary Penalties Law (CMPL)

Source: U.S. Department of Health & Human Services

Stark Law / Anti-kickback Statute and False-Claims

Stark Law, anti-kickback statute, and false-claims investigations can be pursued by the government as a civil or criminal matter. Kennedy Attorneys & Counselors at Law helps any of our clients involved in these matters to navigate the process and reduce sanctions, if possible.

Medicare and Medicaid Fraud Defense

Egregious cases of Medicare and Medicaid fraud, such as submitting claims for services never received by the patient, are pretty cut and dry. But health care providers should be careful that they are not inadvertently committing unintended fraudulent acts. Having legal counsel present when talking to investigators is not an admission of guilt. It’s just good business.

Health Care Enforcement Action Defense

Federal and state agencies are very serious about combating health care fraud and investigations and prosecutions have become much more aggressive in recent years. Even an investigation can ruin you professionally and financially. In such a situation, only a skilled and experienced health care enforcement action defense lawyer can help you clear your name.