Texas is on the front lines of the federal government’s battle against Medicare fraud. The defense attorneys of The Oberheiden Law Group, PLLC provide strategic, experience-based legal representation for health care service providers and other entities in the health care industry that are facing federal Medicare fraud investigations in Texas.

Our Health Care Fraud Defense Group is headed by senior attorney Dr. Nick Oberheiden, who bring extensive experience to representing health care providers, executives, and other targets of Medicare fraud investigations. Dr. Oberheiden is a recognized health care fraud defense attorney with a proven track record of securing results of no civil or criminal liability.

Medicare Fraud in Texas: A Top Federal Priority

Texas is one of nine areas in the country where the federal government has stationed two teams from its elite Health Care Fraud Prevention and Enforcement Action Team (HEAT) task force. HEAT is a coordinated effort of the Department of Justice (DOJ), the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), and other federal agencies, and the fact that there two HEAT teams in Texas while there are only seven other teams across the entire country tells you just how aggressively the federal government is targeting the Texas health care industry.

As a result, health care providers throughout the state are increasingly finding themselves the targets of federal investigations. Unfortunately, this includes many innocent providers who are being targeted simply because they submit a high volume of reimbursement claims to the Centers for Medicare and Medicaid Services (CMS) – without any evidence of fraudulent conduct.

Understanding Medicare Fraud

Medicare Fraud: An Overview

Medicare fraud involves submitting false, fictitious, or otherwise wrongful reimbursement claims for services, medications, and supplies provided to Medicare beneficiaries. Depending on the specific fraudulent practices involved, prosecutors can bring Medicare fraud charges under a variety of different federal statutes. These include:

  • False Claims Act – The False Claims Act prohibits knowingly submitting false statements or making misrepresentations of fact in connection with a claim for reimbursement under Medicare or another federal health care benefit program.
  • Anti-Kickback Statute – The Anti-Kickback Statute prohibits knowingly soliciting, paying, or accepting any form of remuneration that is ultimately reimbursed under a federal health care benefit program in connection with a referral for health care services, medication, supplies, or equipment.
  • Physician Self-Referral Laws (Stark Law) – The Stark Law prohibits “physician self-referrals,” which are referrals for “designated health services” to entities in which the referring physician or an immediate family member has an ownership or financial interest.

Medicare fraud can involve violations of the Social Security Act and various provisions of the U.S. Criminal Code as well. In fact, in Medicare fraud investigations, it is not unusual for targets to face allegations of illegal activity under multiple different federal laws.

Common Examples of Medicare Fraud

HEAT, the DOJ, and other federal agencies are actively pursuing companies and individuals suspected of all forms of Medicare fraud. Some of the most common allegations in federal Medicare fraud investigations include:

  • Billing for services that were not performed (also known as “phantom billing”);
  • Billing for supplies and equipment that were not actually purchased;
  • Billing for services, supplies, and equipment that were not medically necessary;
  • Obtaining fraudulent certifications for services that were medically unnecessary (a common allegation in home health and hospice fraud investigations);
  • Obtaining fraudulent certifications for medically unnecessary supplies (including durable medical equipment (DME));
  • Falsifying patient records;
  • Double-billing;
  • Upcoding, unbundling, and other forms of coding fraud; and
  • Offering and accepting kickbacks.

Physicians, nurses, home health care centers, hospice care centers, nursing homes, registered care facilities, hospitals, pharmacies, toxicology laboratories, DME companies, physician syndications, DNA testing centers, cancer treatment centers, and other health care service providers in Texas are all potentially at risk for facing penalties as the result of a Medicare fraud investigation.

Civil and Criminal Penalties for Medicare Fraud

The penalties for Medicare fraud can be severe. If you or your company is found civilly or criminally responsible, these penalties can include:

  • Recoupment requests;
  • Non-payment of future claims;
  • Civil fines of up to $11,000 per false claim;
  • Exclusion from future participation in federal health care programs (including Medicare);
  • Treble damages;
  • Government attorneys’ fees;
  • Criminal fines; and
  • Federal imprisonment.

The possible prison sentences for Medicare fraud include:

  • Medicare fraud – Up to 10 years in prison for each count of fraud.
  • Medicare fraud with serious bodily injury – Up to 20 years in prison (common in cases involving reimbursement requests for counterfeit or excessive medication).
  • Medicare fraud causing death – Life imprisonment.

Physicians and other medical professionals can face licensing actions and loss of hospital privileges as well.

Three Keys to Successfully Defending a Medicare Fraud Investigation

Early Intervention

In a Texas Medicare fraud investigation, hiring a defense attorney to intervene early can be the key to avoiding criminal charges. If you can keep your case civil, prison time will be off of the table, and you will have a better chance of escaping your investigation without incurring any legal liability.

The Oberheiden Law Group, PLLC seeks to make contact with the prosecutor’s office within the first hours of being hired to defend against a Medicare fraud investigation. We will seek immediate answers to questions such as:

  • Is the case civil or criminal?
  • What prompted the investigation?
  • What is the case about?
  • Who else is under investigation?
  • What agencies are involved?
  • What is the government’s ultimate goal?
  • How can the issue be resolved?

Asserting Statutory Defenses

In many Texas cases, targets of federal Medicare investigations will have several statutory defenses available. Many statutes, including the Anti-Kickback Statute and the Stark Law, contain a number of safe harbors and other clauses that can be used to shield health care providers from liability.

As one example, in a recent case, the government accused our client of fraudulently certifying a patient for home health care services. As part of our defense, we asserted a recognized statutory exception that insulated our client from liability for Medicare fraud. In another recent Medicare fraud case, we were able to use a safe harbor exception to secure a favorable result for our client.

Asserting Lack of Evidence and Intent

If your investigation is criminal in nature, the government will need to prove your guilt “beyond a reasonable doubt.” This is an extremely high standard, and one that requires the government to uncover evidence of two key elements: (i) that you committed an illegal act, and (ii) that you did so with criminal intent.

Most incidents that prompt federal Medicare investigations result from basic organizational and human errors. In fact, in our experience, intentional health care fraud is rare. The Medicare rules and regulations are exceedingly complex. It is easy for providers that are focused on patient care or experiencing rapid growth to make mistakes from time to time. For example, some of the issues that we commonly see include:

  • The use of unqualified staff;
  • Lack of adequate supervision;
  • Relying on delegation & outsourcing;
  • Structural and organizational deficits;
  • Mistakes from oversight or feeling overwhelmed; and
  • An ineffective or no use of a Medicare compliance program.

However, these mistakes to not reflect criminal culpability. As a result, you should never assume that the government is right about your case. The fact that you are under investigation does not mean that you are guilty, and our track record speaks to this fact. When we take your case, absent extraordinary circumstances, our top priorities will be:

  • Case dismissed;
  • No criminal charges;
  • Maintaining your professional license;
  • Civil fine and no criminal plea;
  • Reducing a felony to a misdemeanor; and
  • No prison time.

Considerations for Choosing a Texas Health Care Fraud Defense Lawyer for Your Medicare Fraud Investigation

If you are being investigated for Medicare fraud, your choice of law professionals is important. Medicare fraud cases are extremely complex, and not all lawyers are equipped with the knowledge, experience, and health care insights necessary to present the strongest possible defense.

Health care fraud defense lawyers combine the best qualities of criminal lawyers and health care attorneys. Experienced health care fraud defense attorneys will have handled an impressive amount of billed claims under Medicare and the other government health care benefit programs. They will also have experience working with federal prosecutors and fighting for clients in court. With your business, your finances, and potentially even your future on the line, this is the type of attorney you need on your side.

Make the Right Choice: The Oberheiden Law Group, PLLC

At The Oberheiden Law Group, PLLC, our team of fraud defense lawyers offers the experience of handling over 1,000 health care proceedings conducting more than 200 criminal trials nationwide. Our attorneys have collectively assessed more than 500,000 billed claims. Several of our attorneys come from senior positions within the DOJ, and all of our lawyers have extensive hands-on experience in Medicare fraud investigations.

The attorneys in our Health Care Fraud Defense Group regularly represent business owners, health care executives, lawyers, health care providers, hospitals, hospices, pharmacies, laboratories, medical device companies, and others in complex Medicare fraud investigations throughout Texas. This includes investigations involving:

  • The Department of Defense;
  • The Department of Justice;
  • The Drug Enforcement Administration;
  • The Federal Bureau of Investigation;
  • The Internal Revenue Service;
  • The Medicaid Fraud Control Unit;
  • The Office of Inspector General;
  • Texas law enforcement; and
  • Other state and federal law enforcement agencies.

If you or your business is facing a Medicare fraud investigation in Texas, contact us for a free case evaluation today.

Our Track Record

  • Defense of Medicare laboratory against investigations by the Department of Justice and the U.S. Attorney’s Office for alleged Medicare fraud.
    Result: No civil or criminal liability.
  • Defense of a health care services company against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged False Claims Act and Stark Law violations.
    Result: No civil or criminal liability.
  • Defense of Medicare laboratory against investigations by the Department of Health and Human Services and the Office of Inspector General for alleged health care fraud.
    Result: No civil or criminal liability.
  • Defense of nationally operating health care company against an investigation by the Department of Defense for alleged Tricare fraud.
    Result: No civil or criminal liability.
  • Defense of health care marketing company against an investigation by the Office of Inspector General for alleged False Claims Act and Medicare violations.
    Result: No civil or criminal liability.
  • Defense of a laboratory against an investigation by various branches of the federal government for alleged fraud.
    Result: No civil or criminal liability.
  • Defense of physician-owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged fraud.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by the Department of Justice for alleged fraud.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged Stark Law violations.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged False Claims Act violations.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by various branches of the federal government for alleged False Claims Act, Stark Law, and Medicare violations.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by the Office of Inspector General for alleged fraud.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by the Department of Defense for alleged Tricare fraud.
    Result: No civil or criminal liability.
  • Defense of a physician-owned entity against an investigation by the Department of Justice for alleged Medicare fraud.
    Result: No civil or criminal liability.
  • Defense of physician-owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations.
    Result: No civil or criminal liability.
  • Defense of health care management organization against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged Medicare fraud.
    Result: No civil or criminal liability.
  • Defense of nationally operating laboratory against an investigation by the Office of Inspector General for alleged fraud.
    Result: No civil or criminal liability.

Texas Medicare Fraud Defense Attorneys

Nick OberheidenDr. Nick Oberheiden is a Harvard-trained and internationally educated health care fraud defense attorney who works with clients throughout the United States. Dr. Oberheiden has successfully represented health care executives, business owners, public officials, physicians, and lawyers in high profile prosecutions, accused of political corruption, government investigations, and assisted with media campaigns, including 60 Minutes. Dr. Oberheiden often is able to stop federal investigations before they lead to criminal charges. He also leads internal investigations, implements corporate compliance programs, and teaches U.S. criminal law and federal litigation in the United States and abroad.

Lynette ByrdLynette S. Byrd is a former Assistant United States Attorney (AUSA). Texas clients benefit from Ms. Byrd’s previous experience of prosecuting health care fraud, Anti-Kickback violations, False Claims Act, and Stark violations on behalf of the United States. She knows the law and regularly argues federal matters on behalf of her clients.

We are available every day of the year. You can call us directly or complete our contact form to request a free consultation.

1-888-997-2520
Including Weekends
Oberheiden Law Group, PLLC
Serving Texas and Surrounding Areas
888-997-2520
www.medicare-lawyer.com
This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results do not guarantee similar future outcomes. The Oberheiden Law Group PLLC is a Texas PLLC with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.