When you are under investigation for phantom billing or up-coding, or accused of billing medically unnecessary services, you do not have time to introduce your lawyer to the world of billing, coding, and medical necessity. You must expect your attorneys to know every nuance and detail of your industry so that the focus in times of crisis can immediately switch to strategic defense.
Medicare fraud constitutes a federal felony and monetary liabilities can be enormous. The possibility of being held accountable for Medicare, Medicaid, Tricare, and other healthcare fraud, should caution you to invest your time and resources intelligently into a strategic and thoughtful defense plan. Clearly, the last thing you want is the government to brand you as a criminal or to impose civil liability that causes you to lose the business you’ve created. See our track record for yourself and discuss with us how to keep your record clean.
A Medicare/Medicaid Fraud Defense Team You Can Trust
The attorneys of Piper & Bowers, P.S.C. have successfully defended physicians, practice owners, and physician owned entities in False Claims Act, CMS exclusion, Stark Law, Anti-Kickback, Medicare, and Medicaid investigations. Our healthcare investigation track record is impeccable.
Medicare fraud refers to the submission of false or fictitious claims to a governmental healthcare program. According to government statistics, claims of approximately $50 billion per year are considered suspicious and subject to Medicare fraud investigation. Thus, no matter how well you think you have organized your practice and operations, the chances of being audited by Medicare eventually are real, especially if your practice is successful and you submit high volume claims to the Centers for Medicare and Medicaid Services (CMS). In particular, the following statutes form the basis for Medicare investigations:
False Claims Act
Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment to which the healthcare provider is not entitled, e.g. a laboratory submits claims to Medicare for a higher level of services than actually provided. See, 31 U.S.C. Sect. 3729-3733. For the criminal component of the False Claims Act, see 18 U.S.C. Sect. 287.
Stark Law (Self-Referrals)
Making prohibited referrals for certain designated health services to an entity in which the physician or the physician’s immediate family has an ownership or financial interest or compensation arrangement, e.g. a surgeon refers business to an MRI clinic that his wife owns. See, 42 U.S.C. Sect. 1395nn. For safe harbor exceptions, see 42 C.F.R. Sect. 1001.952.
Anti-Kickback Statute
Knowingly soliciting, paying, and/or accepting any form of remuneration to induce or reward referrals for items or services reimbursed by federal healthcare programs, e.g. an arrangement that is not covered by regulatory safe harbors and whereby cash or other benefits are offered or exchanged for referrals. See, 42 U.S.C. 1320A-7b(b).
Civil Monetary Penalties Law
Examples for civil monetary penalties to arise are presenting a claim that the claimant knew or should have known is for an item or service not provided as claimed or that is false and fraudulent; presenting a claim that the claimant knew or should have known is for an item or service that is not reimbursable by Medicare; or any violation of the Anti-Kickback Statute.
Civil monetary penalties authorize the government to charge up to $ 50,000 per each false claim plus up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, solicited, paid, or received. See, 42 U.S.C. Sect. 1320a-7a
Criminal Fraud Statute
Whoever knowingly or willfully executes or attempts to execute a scheme to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any healthcare benefit program in connection with the delivery of or payment for healthcare benefits, items, or services, shall be fined or imprisoned of up to 10 years, or both. See 18 U.S.C. Sect. 1347.
Healthcare fraud applies not only to healthcare providers, but instead to “anyone,” including physicians, nurses, practice managers, non-licensed individuals, practice owners, healthcare businesses, and even institutions.
Medicare fraud is investigated by the Office of Inspector General (OIG), the Department for Health and Human Services (HHS), the Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), Medicaid Fraud Control Units (MFCUs), and State Medicaid Agencies in cooperation with the Healthcare Fraud Prevention and Enforcement Action Team (HEAT), the General Services Administration (GSA), and the Centers for Medicare and Medicaid Services (CMS).
If found guilty, targets of investigations may be exposed to recoupment requests, non-payment of future claims, civil fines of up to $ 11,000 per false claim, exclusion from federal healthcare programs, treble damages, attorney fees, criminal fines, criminal indictment, or incarceration in a federal prison.
Liability does not require a specific intent to violate the law; in fact, the government does not even need to prove actual knowledge of the wrongfulness of the transaction.
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