Are you a healthcare professional or business owner facing scrutiny from federal authorities? The complexities of healthcare regulations can inadvertently lead to investigations, even if you’ve always acted with integrity. If you’re feeling punished for your success, and the government is threatening your livelihood, you need a robust defense. At internetlawyers.net, our dedicated team of Healthcare Fraud Lawyers understands the intricacies of these cases and is committed to protecting your rights and your future.
We believe in fixing problems, not surrendering to them. Our top-tier trial team comprises former FBI agents, former DOJ staff, and former U.S. Attorneys – no junior lawyers or paralegals. With a high success rate across all 50 states and over 2,000 cases handled, we offer the experience and determination you need.
If you are under investigation and believe you acted without criminal intent, call us immediately at 888-680-1745 for a confidential consultation with Dr. Nick Oberheiden, a leading healthcare fraud lawyer.
Attorney Nick Oberheiden, Healthcare Fraud Team Leader
Understanding Healthcare Fraud: What is It?
Healthcare fraud, at its core, involves schemes designed to illegally access healthcare program funds through false or fraudulent representations. While the government often frames these cases as intentional criminal acts, many arise from unintentional billing and coding errors within the complicated healthcare system. The crucial element in any healthcare fraud trial is intent. Simply having billing errors doesn’t automatically equate to fraudulent intent. However, government agencies aggressively pursue these cases, making it vital to have a skilled healthcare fraud lawyer to defend your interests.
The Government’s Burden of Proof in Healthcare Fraud Cases
When the government accuses you of healthcare fraud, the burden of proof rests squarely on their shoulders. They must demonstrate beyond a reasonable doubt that you knowingly engaged in a scheme to defraud a healthcare program. These programs can include federal entities like Medicare, Medicaid, Tricare, DOL, VA, and even private insurance programs.
Healthcare fraud is a broad term encompassing various actions aimed at illegally obtaining financial benefits at the expense of government or private insurers. Understanding the common examples of healthcare fraud is the first step in ensuring compliance and recognizing potential risks. If you suspect you might be facing an investigation, consulting a healthcare fraud lawyer is crucial for early intervention.
Common Types of Healthcare Fraud
Here are some of the most prevalent forms of healthcare fraud that healthcare fraud lawyers regularly encounter:
Illegal Kickbacks and the Anti-Kickback Statute
The federal Anti-Kickback Statute is a critical law designed to prevent corruption in healthcare. It criminalizes the knowing and willful solicitation, receipt, offer, or payment of anything of value in exchange for patient referrals for services or goods payable by government healthcare programs like Medicare and Medicaid. This includes not only direct payments but also disguised remuneration such as:
- Referral fees
- Finder’s fees
- Bonuses
- Discounted leases
- Research grants
- Excessive compensation arrangements
- Travel and entertainment perks
These provisions are in place to ensure that medical decisions are based on patient needs, not financial incentives. Allegations of kickbacks are serious and require the immediate attention of a healthcare fraud lawyer to navigate the complex legal landscape.
Upcoding: Billing for More Expensive Services
Healthcare billing relies on specific numerical codes to identify procedures and services. Government programs assign payment amounts to each code. Upcoding is a fraudulent practice where providers bill for more expensive or complex services than what was actually performed. This inflates costs and illegally increases reimbursements. Upcoding is a form of healthcare fraud and a potential violation of the False Claims Act, necessitating defense by a healthcare fraud lawyer.
Billing for Services Not Rendered
A straightforward type of healthcare fraud is billing for services that were never provided to patients. This can involve fabricating patient encounters or billing for procedures that simply did not occur. Such actions are easily detectable in audits and can lead to severe penalties, highlighting the need for a strong healthcare fraud lawyer.
Ghost Patients: Fabricated or Non-Serviced Patients
Ghost patients are fictitious individuals or real patients who did not receive the services billed under their names. Submitting claims for ghost patients is a blatant form of healthcare fraud. These cases often involve sophisticated schemes and require a skilled healthcare fraud lawyer to unravel the allegations and build a defense.
Inflating Cost Reports: Medicare Fraud in Hospitals
Hospitals and healthcare institutions that treat Medicare patients are reimbursed for certain costs. They must submit Cost Reports to Medicare detailing these expenses. Fraudulent activities involving cost reports include:
- Falsely inflating patient care costs
- Seeking reimbursement for non-patient care related expenses
- Claiming costs for non-Medicare patients
- Manipulating statistics to maximize reimbursement
Cost report fraud is a complex area often requiring forensic accounting and legal expertise, making a healthcare fraud lawyer with experience in these matters essential.
Medicare Part D Fraud: Prescription Drug Schemes
Medicare Part D, the prescription drug benefit program, is vulnerable to fraud. Common schemes include:
- Duplicate billing for prescriptions
- Overcharging for medications
- Enrollment fraud to gain access to the program
- Redlining or discriminatory practices
- Improper rebates from pharmaceutical manufacturers
Given the scale of Medicare Part D, fraud in this area is a major concern, and individuals facing allegations need a knowledgeable healthcare fraud lawyer.
Lack of Medical Necessity: Unnecessary Services
Healthcare services must be medically necessary to qualify for payment from government programs. Providers are legally obligated to document the medical necessity of treatments and services for which they seek reimbursement. Billing for services, tests, or devices lacking medical necessity is a frequent type of healthcare fraud. Defending against these allegations requires demonstrating the medical rationale, often with the help of a healthcare fraud lawyer.
Improper Financial Interests: Stark Law Violations
The Stark Law and similar state regulations prevent physicians from having prohibited financial relationships with entities to which they refer patients for certain “designated health services.” This includes ownership interests or compensation arrangements. Violations can trigger False Claims Act liability. Navigating Stark Law compliance and defense requires specialized knowledge, making a healthcare fraud lawyer essential.
Bundling and Unbundling: Manipulating Billing Codes
Unbundling involves billing separately for procedures that should be billed together at a lower combined rate under Medicare and Medicaid guidelines. This illegally inflates profits. Conversely, improper bundling can also raise red flags. Accurate coding is crucial, and errors can lead to investigations, necessitating a healthcare fraud lawyer to address potential allegations.
False Certification: Misrepresenting Compliance
Providers must provide certifications regarding medical necessity, service performance, and regulatory compliance when submitting claims. Falsifying these certifications to get claims paid or gain business is healthcare fraud and can also violate the False Claims Act. Defending against false certification allegations requires demonstrating the truthfulness of the certifications, often with the assistance of a healthcare fraud lawyer.
Penalties for Healthcare Fraud and the Role of a Defense Lawyer
The primary goal of a healthcare fraud lawyer is to prevent criminal investigations and mitigate penalties. Experienced attorneys, especially former federal prosecutors, can often steer cases toward civil resolutions, protecting professional licenses and avoiding criminal charges. However, when facing serious allegations, the penalties can be severe, ranging from substantial civil fines to imprisonment.
How Experienced Healthcare Fraud Defense Lawyers Resolve Cases
Most healthcare fraud cases revolve around allegations of fraudulent billing claims submitted to government or commercial insurers. While billing errors are common in the complex healthcare system, government intervention typically occurs when the alleged fraud is systematic, widespread, and financially significant – often exceeding hundreds of thousands of dollars.
The government’s definition of “fraud” is often broad, alleging lack of medical necessity, substandard care (e.g., excessive testing), inflated billing, or billing for services not provided. Oberheiden P.C. has a proven track record of successfully resolving these and other healthcare fraud charges. Early intervention is key to a favorable resolution. Contacting a healthcare fraud lawyer at the first sign of an investigation is crucial.
Recognizing a Healthcare Fraud Investigation
You might be under investigation if you receive:
- Healthcare audit requests
- Civil Investigative Demands (CIDs)
- Subpoenas from HHS-OIG
- Grand Jury Subpoenas from the DOJ
- Federal search warrants
- Indictments
Each of these scenarios requires a nuanced defense strategy tailored by an experienced healthcare fraud lawyer. Delaying action can severely limit your options.
Proactive Defense: The Key to Avoiding Charges
Attorney Nick Oberheiden emphasizes that timing is critical in healthcare fraud investigations. A proactive, determined approach is far more effective than waiting and hoping the issue resolves itself. His strategy involves early intervention, explanation, clarification, and resolution.
Examples of Successful Case Resolutions:
- Target Letter Resolved (No Charges Filed): A client received a target letter in a federal healthcare fraud case. Previous counsel had been inactive. By immediately engaging with the FBI and prosecutor and presenting crucial information the government was unaware of, charges were avoided.
- Search Warrant Defense (No Charges Filed): After the FBI executed a search warrant on a client’s business, aggressive legal action by a healthcare fraud lawyer prevented any charges from being filed.
- Grand Jury Subpoena Defense (No Charges Filed): A business served with a grand jury subpoena was successfully defended, and charges were avoided through strategic legal representation.
These real-world examples underscore the importance of immediate action and experienced legal counsel when facing healthcare fraud allegations. Don’t wait – call a healthcare fraud lawyer today.
Federal Healthcare Fraud Statutes: 18 U.S.C. § 1347 and Beyond
Federal law 18 U.S.C. § 1347 specifically addresses healthcare fraud. Oberheiden P.C. has a successful record in cases under this statute:
- United States v. Client (Medicare Fraud, Probation Obtained): Client indicted for $7 million Medicare fraud. Healthcare fraud lawyer Nick Oberheiden secured probation, avoiding imprisonment.
- United States v. Client (Medicare Fraud, Probation Obtained): Client indicted for $3 million Medicare fraud. Probation obtained through effective defense.
- United States v. Client (Medicaid Fraud, Probation Obtained): Client indicted for over $1 million Medicaid fraud. Probation secured, avoiding significant penalties.
These are just a few examples. Oberheiden P.C. has a history of winning healthcare fraud cases.
Anti-Kickback Statute: 42 U.S.C. § 1320a-7b Defense
Kickback allegations are common in healthcare fraud investigations. Even seemingly innocuous benefits can be construed as illegal kickbacks. Defending these cases requires:
- Deep Healthcare Law Expertise: Understanding the nuances of the Anti-Kickback Statute and its safe harbors.
- Negotiation Skills: Effectively arguing your client’s position with government investigators and prosecutors.
Oberheiden P.C. has successfully defended numerous civil and criminal kickback cases nationwide, leveraging both legal acumen and negotiation prowess. A skilled healthcare fraud lawyer is essential in these complex cases.
False Claims Act: 31 U.S.C. § 3729 et seq. Defense
False Claims Act (FCA) cases often originate from whistleblower lawsuits. These qui tam actions are filed by individuals (often former employees) alleging fraud against the government. The first sign of an FCA investigation is often a Civil Investigative Demand (CID) or government subpoena.
The priority in FCA defense is to prevent the case from becoming criminal. Oberheiden P.C. has a perfect record of preventing criminal charges in FCA investigations. They also specialize in asset protection, working to dismiss or favorably settle FCA cases, safeguarding clients’ financial stability. If you are facing an FCA investigation, you need a healthcare fraud lawyer with experience in whistleblower cases.
Aggravated Identity Theft in Healthcare Fraud
Aggravated identity theft charges are increasingly being added to healthcare fraud indictments by the DOJ. Each count carries a mandatory two-year prison sentence, with no probation option. Oberheiden P.C. has successfully argued against the applicability of aggravated identity theft charges in healthcare fraud cases, saving clients from lengthy prison terms. This highlights the critical need for experienced healthcare fraud lawyers who stay ahead of evolving prosecutorial tactics.
Federal Conspiracy Charges: 18 U.S.C. § 1349 Defense
Many federal healthcare fraud cases include conspiracy charges, alleging that multiple individuals collaborated in a fraud scheme. For example, a marketer, doctor, and pharmacy could face conspiracy charges for a kickback arrangement. Oberheiden P.C. has a strong track record of defending against conspiracy charges, breaking down the government’s claims and protecting clients. A healthcare fraud lawyer experienced in conspiracy defense is vital in these multi-defendant cases.
Additional Case Results: No Charges Filed
Oberheiden P.C.’s success extends beyond courtroom victories to preventing charges altogether:
- Texas Nurse Practitioner (No Charges): Targeted in a kickback investigation, Oberheiden P.C. proved their client was a victim of theft, not a perpetrator. The government dropped the investigation, and no charges were filed.
- Texas Woman in Pharmacy Kickback Scheme (No Charges): Facing FBI scrutiny, Oberheiden P.C. convinced the government their client was a minor player, leading to a declination to prosecute.
- DOL Investigation – Jaid Hospitality (No Penalties): Successfully resolved a Department of Labor investigation for a hotel client without any civil monetary penalties.
These results demonstrate the effectiveness of proactive and skilled healthcare fraud lawyers in navigating complex government investigations.
Healthcare Fraud FAQs: Your Questions Answered
Types of Healthcare Fraud Defense Attorneys
There are different types of attorneys specializing in healthcare fraud defense:
- Civil Defense Attorneys: Represent providers in disputes with insurance companies and private entities.
- State Defense Attorneys: Handle cases involving state agencies like Attorney General offices and Medicaid Fraud Control Units (MFCUs).
- Federal Defense Attorneys: Focus on federal healthcare fraud matters (Medicare, Medicaid, Tricare, DOL, VA). Oberheiden P.C. specializes in federal defense, providing experienced healthcare fraud lawyers for these high-stakes cases.
Who Investigates Healthcare Fraud?
Numerous federal and state agencies investigate healthcare fraud, including:
- HHS-OIG
- CMS
- DOD & VA
- DOL
- DOJ
- MFCUs
- FBI
- IRS-CI
Contractors like MACs, RACs, and UPICs also conduct audits. Private insurers also investigate fraud. These investigations can lead to recoupments, penalties, and even criminal charges, making a healthcare fraud lawyer essential.
Elements of Healthcare Fraud
The elements of healthcare fraud vary depending on whether it’s a civil or criminal case. Under 18 U.S.C. Section 1347 (criminal healthcare fraud), the elements are:
- Knowingly and willfully
- Executing or attempting to execute a scheme
- To defraud a healthcare benefit program
- In connection with healthcare services or benefits
Other statutes like the Anti-Kickback Statute, False Claims Act, and Stark Law also define healthcare fraud and impose penalties. A healthcare fraud lawyer understands these nuances and can build a defense based on the specific allegations.
Major Types of Healthcare Fraud and Abuse
Healthcare fraud encompasses a wide range of offenses, including:
- Prohibited referrals (Stark Law)
- Falsifying records
- Illegal remuneration (Anti-Kickback Statute)
- Overbilling (Medicare, Medicaid, Tricare, etc.)
- Upcoding, unbundling, phantom billing
- Lack of medical necessity
These diverse forms of fraud require a healthcare fraud lawyer with broad expertise to effectively defend clients.
Nationwide Federal Healthcare Fraud Defense
Oberheiden, P.C.’s healthcare fraud lawyers represent clients nationwide in all federal healthcare fraud matters involving CMS, DEA, DOJ, and OIG. Facing federal fraud allegations is extremely serious. If you are targeted for Medicare, Medicaid, Tricare, or DOL fraud, you need the best defense possible.
Federal prosecutors can pursue civil and criminal charges under various statutes. Understanding the specific allegations is the first step in building an effective defense. Are you accused of overbilling? Kickbacks? Improper opioid prescribing? A healthcare fraud lawyer will quickly assess the situation and develop a strategy.
For a free and confidential case assessment, call 888-680-1745 to speak with a senior healthcare fraud defense lawyer at Oberheiden, P.C.
Choosing the Right Healthcare Fraud Lawyer: Key Considerations
Healthcare fraud is a serious offense with severe penalties. Choosing the right healthcare fraud lawyer is crucial. General lawyers may not have the specialized knowledge needed for these complex cases. When selecting counsel, look for:
- Healthcare Law Background: Deep familiarity with healthcare regulations, fraud statutes, and industry practices.
- Government Experience: Proven experience dealing with government investigations, FBI agents, and prosecutors.
- Track Record: A history of success in healthcare fraud cases, including avoiding charges and achieving favorable outcomes.
Why Choose Oberheiden, P.C. for Your Federal Healthcare Fraud Matter?
- Immediate Action: We start working on your defense immediately, leveraging our extensive experience in healthcare law and federal investigations.
- Efficient and Discrete Resolution: We understand the sensitivity of these cases and strive for a favorable and discreet outcome as quickly as possible.
- Prompt Risk Assessment: We quickly identify the allegations against you, assess the potential risks, and develop a targeted defense strategy.
- Trial-Ready: If trial is necessary, our experienced trial team is fully prepared to aggressively defend your rights in court.
- Informed Decision-Making: We guide you and your team through the complexities of the investigation, helping you avoid critical mistakes and make informed decisions.
Put Our Highly Experienced Team on Your Side Today
Our team includes:
- Dr. Nick Oberheiden: Founder, Attorney-at-Law, leading healthcare fraud lawyer.
- Lynette S. Byrd: Former DOJ Trial Attorney, Partner.
- Brian J. Kuester: Former U.S. Attorney.
- Hon. Kevin McCarthy: Former Speaker of the House (ret.), Government Consultant.
- Mike Pompeo: Of Counsel, Former U.S. Secretary of State.
- John W. Sellers: Former Senior DOJ Trial Attorney.
- Linda Julin McNamara: Federal Appeals Attorney.
- Jennifer W. Corinis: Litigation Counsel.
- Roger Bach: Former Special Agent (DOJ).
- Chris J. Quick: Former Special Agent (FBI & IRS-CI).
- Michael S. Koslow: Former Supervisory Special Agent (DOD-OIG).
- Ray Yuen: Former Supervisory Special Agent (FBI).
This team of former prosecutors and agents brings unparalleled experience to your defense. When facing healthcare fraud allegations, you need a healthcare fraud lawyer with a proven track record and the resources to fight for you.
Our Federal Healthcare Fraud Defense Practice Areas
We represent clients in a wide range of federal healthcare fraud matters, including:
- Overbilling Medicare, Medicaid, Tricare, DOL
- Improper opioid prescribing/diversion
- Phantom billing
- Improper physician certifications
- Billing for medically unnecessary services
- Falsifying patient records
- Double-billing
- Illegal kickbacks and referral fees
- Billing and coding violations (upcoding, unbundling)
- Attempt and conspiracy to commit healthcare fraud
Are You Accused of a Federal Crime? Don’t Delay.
Learn about your rights and options. Call Dr. Nick Oberheiden now at 888-680-1745 for immediate assistance. We are available nights and weekends.
Proven Results at All Stages of Healthcare Fraud Prosecution
Our healthcare fraud lawyers have a proven track record of success at every stage of healthcare fraud proceedings:
- Fee-For-Service Contractor Audits (MAC, RAC, ZPIC): We represent providers in audits and appeals involving Medicare contractors, challenging inaccurate findings and protecting our clients from unwarranted recoupments and penalties.
- Federal Investigations: We excel at representing clients during the investigative stage, proactively engaging with agencies like CMS, DEA, DOJ, FBI, IRS, and OIG to minimize or eliminate civil and criminal liability.
- Grand Jury Proceedings: We provide aggressive representation in grand jury investigations, challenging subpoenas and protecting clients from indictment.
- Pre-Trial Practice and Plea Deal Negotiations: We leverage pre-trial strategies to dismiss charges, negotiate favorable plea agreements, and protect our clients from the risks of trial.
- Trials and Sentencing: Our experienced trial attorneys are prepared to vigorously defend clients at trial and advocate for lenient sentencing if necessary.
- Appeals: Our appellate team represents clients before U.S. Circuit Courts of Appeal, challenging adverse rulings and pursuing justice.
Facing healthcare fraud allegations is daunting, but you don’t have to face it alone. Contact internetlawyers.net today and speak with a leading healthcare fraud lawyer who will fight tirelessly to protect your future. Call 888-680-1745 now.
