Healthcare providers in Connecticut are at risk for being targeted by the U.S. Department of Justice (DOJ), U.S. Department of Health and Human Services Office of Inspector General (OIG), Connecticut Medicaid Fraud Control Unit (MFCU), and other state and federal authorities. If your business or practice is being targeted in an audit or investigation, it is important that you seek legal representation immediately.
Medicare fraud and Medicaid fraud are multi-billion-dollar industries. While much of these programs’ losses result from intentional fraud by individuals and organizations seeking to take advantage of the flaws in the system, unintentional billing violations account for a significant portion as well. As a result, while state and federal authorities devote significant resources to taking down Medicare and Medicaid scams, they also aggressively pursue legitimate providers suspected of overbilling these healthcare benefit programs.
We know from experience. Oberheiden, P.C. is a team of healthcare fraud defense lawyers who have been practicing collectively for well over 100 years. Approximately half of our experience comes from time working inside of the U.S. Department of Justice (DOJ) and state prosecutors’ offices, where our attorneys pursued investigations and charges against providers suspected of engaging in Medicare and Medicaid fraud. Having handled thousands of cases from both sides, we offer solid insights for providers in Connecticut, and we are able to use our experience to help providers avoid the civil and criminal penalties that can flow from state and federal investigations.
When Can a Healthcare Provider Be Charged with Medicare or Medicaid Fraud?
The legal definitions of Medicare and Medicaid fraud are extremely broad, far broader than most healthcare providers realize. In order to be prosecuted for Medicare or Medicaid fraud, you do not need to overbill one of these programs intentionally. To face civil penalties for fraud under the False Claims Act and other statutes, it is enough to simply obtain improper payment without the intent to defraud the government. Evidence of intent can support criminal charges for Medicare or Medicaid fraud but the government can seek civil monetary penalties (CMPs) and program exclusion even in the absence intentional wrongdoing.
Experienced Legal Representation for Healthcare Providers in Connecticut
If your healthcare business or practice is being targeted in a Medicare or Medicaid fraud investigation, what do you need to do? First and foremost, you need to seek experienced legal representation. Agencies such as the DOJ, OIG, MFCU, Centers for Medicare and Medicaid Services (CMS), Federal Bureau of Investigation (FBI), and the Drug Enforcement Administration (DEA) have teams of investigators and prosecutors who are devoted to prosecuting healthcare fraud. You need to assemble your own team in order to level the playing field.
At Oberheiden, P.C., we put experience on your side. As former DOJ and state-level prosecutors focusing on healthcare fraud enforcement, we know the government’s tactics in these cases because in some cases our former government prosecutors helped to develop them. We also understand how to overcome these tactics, as evidenced by our extensive track record of successful representation in complex Medicare and Medicaid fraud matters. If your medical practice or healthcare business is under investigation or facing an audit, we can help you. The sooner we get started, the better your chances will be to avoid civil liability and criminal penalties entirely.
Our Services for Medicare and Medicaid Fraud Matters
Our healthcare fraud defense team represents Connecticut providers in all Medicare and Medicaid fraud-related matters. This includes: (i) fraud investigations, (ii) CMS contractor audits, and (iii) civil and criminal litigation.
Medicare and Medicaid Fraud Investigations
There are a few different factors that can trigger Medicare and Medicaid fraud investigations. Many of these investigations are the result of state and federal authorities increasingly-heavy reliance on data analytics. With the enormous volume of Medicare and Medicaid claims submitted on a daily basis, it simply is not possible for government personnel to keep tabs on individual providers billing practices. As a result, the DOJ, OIG, CMS, and other agencies have adopted data analytics tools that they use to identify “anomalies” which are often (though not always) indicative of fraud.
Another key factor in the large number of Medicare and Medicaid investigations is the existence of qui tam (or “whistleblower”) litigation. Under the federal False Claims Act and the analogous Connecticut statute (Chapter 55e), individuals can report suspected cases of fraud to the government and receive financial compensation if their tips lead to fines and recoupments. While these whistleblower provisions serve to help the government tackle the growing problem of Medicare and Medicaid fraud and abuse, they are also highly-susceptible to abuse by disgruntled former employees and competitors.
Regardless of the factors that triggered your investigation, you need to take it extremely seriously. The civil penalties for Medicare and Medicaid fraud are substantial, and criminal prosecution can result in long-term imprisonment. The best way to avoid these consequences is to attack your investigation head-on by challenging investigators methods and assumptions, and demonstrating to prosecutors that they do not have sufficient evidence to pursue charges against you. Our attorneys represent healthcare providers in Connecticut and nationwide in investigations involving:
- False Claims Act
- Stark Law
- Anti-Kickback Statute
- State Medicaid fraud and control laws
- Other healthcare and criminal laws
- OIG and grand jury subpoenas
CMS Medicare and Medicaid Contractor Audits
In addition to state and federal investigations, Connecticut healthcare providers are also regularly targeted in audits conducted by contractors working under CMS’s “fee-for-service” audit recovery program. This includes audits conducted by National Government Services, Inc. (NGS) and Noridian Healthcare Solutions, LLC. Audits are different from investigations in that they do not involve CMS or other government agencies directly, but they are similar in that they can lead to recoupments, denial of payments, pre-payment review, program exclusion, and other financial and non-financial penalties. CMS’s audit contractors can also refer providers to the DOJ, OIG, and other law enforcement agencies for prosecution and it is not unusual for an audit to be followed by an exhaustive federal investigation.
At Oberheiden, P.C., we represent all types of providers in Medicare and Medicaid audits involving:
- Zone Program Integrity Contractors (ZPICs)
- Recovery Audit Contractors (RACs)
- Medicare Administrative Contractors (MACs)
- Audit Medicaid Integrity Contractors (MICs)
We also have extensive experience with Medicare and Medicaid audit appeals. If you go through an audit without legal representation, there is a strong chance that you will receive an unfavorable determination. While this determination could be valid, there is also a strong chance that it is partially or entirely based on flawed assumptions, methodologies, or interpretations of the Medicare or Medicaid billing regulations. We represent providers at all stages of the appeals process, including requests for redetermination, administrative hearings, and appeals in federal district court.
Civil and Criminal Medicare and Medicaid Fraud Litigation
When audits and investigations lead to charges, avoiding civil and criminal penalties requires an aggressive and detail-oriented approach to litigation. Our healthcare fraud defense team has a significant record of success in civil and criminal matters, and we have represented providers in trials across the country. However, we also know that going to trial is not your only option and in many cases, it will not be the best option on the table. We routinely negotiate favorable resolutions with prosecutors, and we have even been successful in having our clients criminal indictments dismissed prior to trial.
Frequently-Asked Questions (FAQs): Medicare and Medicaid Fraud in Connecticut
Q: What is the Connecticut Medicaid Fraud Control Unit (MFCU)?
The Medicaid Fraud Control Unit (MFCU) is the state authority responsible for investigating and prosecuting cases of suspected Medicaid fraud in Connecticut. As stated on the MFCU’s website, it “protects the State of Connecticut and its taxpayers by investigating and prosecuting fraud committed by those healthcare professionals and facilities who provide services paid for by Medicaid, the government health insurance program for lower income people.”
The MFCU targets healthcare providers suspected of engaging in all forms of fraud, including:
- “Billing for treatment, medical procedures or equipment that is not actually performed or provided;
- “Double billing, which means billing both the Medicaid program and the recipient or his or her private insurance for the same service;
- “Billing for services that are not medically required;
- “Filling a prescription with a generic drug while billing Medicaid for the higher priced brand-name drug;
- “Kickbacks, or giving or accepting something in return for medical services; [and]
- “Up-coding, which is billing Medicaid for a more expensive procedure or service than was actually performed or provided.” (MFCU website)
Q: If I have received a subpoena, does this mean that I am being charged with Medicare or Medicaid fraud?
No, a subpoena is an investigative tool, not a charging document. However, a subpoena can lead to charges for Medicare or Medicaid fraud, particularly in instances where providers fail to take appropriate measures in response to the government’s demand for documents or testimony. If you have received an OIG subpoena, you need to quickly assess the scope of your obligations and any potential grounds for challenging the subpoena’s authority. If you have received a grand jury subpoena, you need to make sure you have a clear understanding of the grand jury process and you should begin preparing your testimony immediately. Our attorneys can guide you through the entire process; and if your subpoena is overly-broad, we can work with the OIG in order to attempt to limit your disclosure obligations.
Q: What are some potential defenses to allegations of Medicare or Medicaid fraud?
Determining which defenses you have available is one of the first steps toward avoiding civil and criminal penalties once you discover that you are being targeted in a Medicare or Medicaid fraud investigation. Putting together your defense strategy requires a comprehensive understanding of the facts involved in your case as well as knowledge of the specific charges that prosecutors are considering. With that said, some of defense strategies we commonly deploy in Medicare and Medicaid fraud investigations include:
- Challenging Constitutional violations during the investigative process
- Challenging auditors’ and investigators’ assumptions and methodologies
- Challenging prosecutors’ evidence of individual elements of each alleged offense
- Asserting safe harbors and other affirmative defenses
- Keeping cases civil in nature
- When necessary, negotiating for reduced charges and sentencing
Q: What are the penalties for Medicare and Medicaid fraud?
Similar to the defenses you have available, the penalties you are facing are heavily dependent upon the scope and nature of the allegations against you. In False Claims Act, Anti-Kickback Statute, and Stark Law investigations, the potential penalties include the following:
False Claims Act Penalties: Civil
- Fines of approximately $21,500 per false claim (as of 2017)
- Treble damages (three times the government’s actual losses)
- Recoupment of overbilled amounts
- Pre-payment review and non-payment of future claims
- Medicare and Medicaid program exclusion
False Claims Act Penalties: Criminal
- Up to $250,000 in fines per violation
- Recoupment of overbilled amounts
- Medicare and Medicaid program exclusion
- Up to five years of federal incarceration per violation
Anti-Kickback Statute Penalties: Civil
- False Claims Act liability
- Recoupments
- Treble damages
- Civil monetary penalties of $50,000 per violation
- Medicare and Medicaid program exclusion
Anti-Kickback Statute Penalties: Criminal
- Up to $75,000 in fines per violation
- Up to five years of federal incarceration per violation
Stark Law Penalties: Civil (the Stark Law does not include provisions for criminal penalties)
- False Claims Act liability
- Recoupments
- Treble damages
- Civil monetary penalties of $15,000 per violation
- Additional CMPs for “knowing” violations
However, it is important to note that prosecutors will often pursue charges for a variety of ancillary offenses in addition to pursuing charges under these healthcare-specific statutes. The statutes outlawing conspiracy, money laundering, mail fraud, wire fraud, and other related offenses all include provisions for substantial fines and prison time that can be added to your sentence should you be found guilty.
Q: Can I lose my license and hospital privileges as the result of a Medicare or Medicaid fraud investigation?
Yes. In addition to facing civil or criminal penalties for healthcare fraud, providers targeted in Medicare and Medicaid fraud investigations can face various other indirect consequences as well. These include licensing action by the Connecticut Medical Examining Board and loss of hospital privileges. In addition to fighting to protect our clients against court-imposed penalties, we take an aggressive approach to fending off these types of additional consequences. To date, not a single client of ours has lost the ability to practice as the result of an investigation in which we have been involved.
5 Reasons Connecticut Healthcare Providers Choose Oberheiden, P.C.
When your financial security, your license to practice or run your business, and potentially even your freedom are all on the line, your choice of legal representation matters. Here are five reasons why Connecticut healthcare providers choose the healthcare fraud defense team at Oberheiden, P.C.:
- Our Background as State and Federal Healthcare Fraud Prosecutors: Many of our attorneys spent decades as state and federal healthcare fraud prosecutors prior to entering private practice.
- Our Comprehensive Approach to Avoiding Unwarranted Consequences: We never stop fighting for our clients. Whether you are under investigation or under indictment, we will continue to constantly explore ways to favorably resolve your case prior to trial.
- Our Team Approach to Healthcare Fraud Defense: We take a team approach to every case we handle. This means that you will have over 100 years of combined experience in your corner.
- Our Commitment to Client-First Legal Representation: When you call, we answer. You will have direct access to the attorneys on our healthcare fraud defense team throughout your case, and we will develop and execute a customized case strategy focused on securing a favorable outcome as quickly as possible.
Contact Us about Your Connecticut Medicare or Medicaid Fraud Investigation
If you need legal representation for a Medicare or Medicaid audit or investigation in Connecticut, contact us now to get started with a confidential case assessment. You can call us 24/7 at (888) 356-4634, or send us your information online and we will respond as quickly as possible.