Medicare Fraud in Detroit
Medicare fraud refers to submitting false or fictitious claims to a governmental healthcare program such as Medicare, Medicaid, Tricare, or federal workers’ compensation. As such, Medicare Fraud encompasses wrongdoing that falls under the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Laws (Stark Law), the Social Security Act, or the U.S. Criminal Code. While Medicare Fraud has many facets, all definitions have in common that a healthcare provider or entity illegally received money from a federal healthcare program.
Detroit plays a central role in Medicare investigations. Detroit is home to many retirees and the city has some of the largest number of Medicare beneficiaries nationwide. Because of the sheer volume of Medicare services in Detroit, the Centers for Medicare and Medicaid Services (CMS) is keeping a close eye on use of Medicare benefits in Detroit. In fact, Detroit is one of only nine U.S. cities in which the federal government has established special task forces to monitor, investigate, and prosecute Medicare Fraud.
Healthcare practitioners and businesses in Detroit must understand that government prosecutions in Detroit are more aggressive and significantly more frequent than in other communities and spearheaded by the elite Health Care Fraud Prevention and Enforcement Action Team (HEAT). HEAT is a coordinated federal task force composed of prosecutors from the Department of Justice (DOJ), Department of Health and Human Services (HHS), the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), and others.
Forms of Medicare Fraud
Medicare Fraud refers to submitting false or fictitious claims to a governmental healthcare program. Medicare Fraud cases allege fraudulent billing practices and reimbursement requests for false, excessive, or unauthorized services and may involve one of these acts.
- Billing for Services Never Performed (Phantom Billing)
- Billing for Services that Were Medically Unnecessary
- Billing for Supplies and Equipment that Were Never Ordered
- Billing for Supplies and Equipment that Were Medically Unnecessary
- Certification for Services that Were Medically Unnecessary (e.g., Home Health or Hospice Fraud)
- Certification for Supplies that Were Medically Unnecessary (e.g., DME)
- Double Billing, Up-Coding, Inflating Bills
- Overutilization of Services or Equipment
- Offering or Accepting Kickbacks
Physicians, nurses, home healthcare centers, hospice care centers, nursing homes, registered care facilities, hospitals, pharmacies, toxicology laboratories, medical devices companies, physician syndications, DNA testing centers, cancer treatment centers, DME companies, and other healthcare service providers are among the most common targets of Medicare Fraud investigations.
What Are the Penalties?
Targets of investigations are exposed to recoupment requests, nonpayment 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.
- Up to 10 years in prison for each count of fraud
- Up to 20 years in prison if the fraud resulted in serious bodily injury (commonly through counterfeit or excessive medication)
- A life sentence if the fraudulent Medicare practice resulted in the patient’s death.
Medical professionals are at risk of being excluded from all federal healthcare programs, prohibited from receiving reimbursement from any federal healthcare program and could face licensing actions and loss of hospital privileges.
Choosing the Right Defense Lawyer
Considering these penalties, clients should select a lawyer who has the skillset and experience to prevail against the government. Because so much can be at stake, healthcare fraud defense strategies are not for beginners and not an area of law with which to experiment.
Healthcare Lawyers. Some people believe that a healthcare lawyer is the right choice to defeat government investigations. Our experience tells us otherwise. Medicare Fraud is often charged jointly with mail fraud, wire fraud, tax evasion, or money laundering, and an effective defense requires an adequate understanding of criminal procedure. Healthcare lawyers do not practice this type of law and they are not trained to negotiate with federal agents, nor do they have the expertise to battle against federal prosecutors in court.
Criminal Lawyers. Although hiring a criminal defense lawyer may sound like the natural thing to do to defend against charges from the government, targets of healthcare fraud prosecutions simply don’t have the time to explain the nuances of healthcare law to a lawyer in a time of crisis. The best criminal defense attorney with a practice focusing on DWI, rape, and drug offenses may not have the record needed to instantly handle complex healthcare fraud matters and may lack familiarity with billing, coding, and medical use rules.
Healthcare Fraud Defense Lawyer. The ideal lawyer that clients in Detroit should look for when they are accused of Medicare Fraud and other healthcare offenses should meet these four criteria.
- Proven Record
- Industry Knowledge
- Profound Familiarity with Healthcare Laws
- Litigation & Trial Expertise
Before investing money, clients should test the lawyer’s specific experience in Medicare Fraud cases. Clients should ask the lawyer candidate these 3 GOLDEN QUESTIONS:
- How many Medicare Fraud cases have you handled so far?
- How many of the healthcare fraud cases that you handled resulted in no civil and no criminal charges or dismissals for your clients?
- How many healthcare fraud cases did you try in court?
Proven Defense Strategies
What makes Oberheiden, P.C. different is our experience and our record. Throughout our careers, our attorneys have handled in excess of 1,000 healthcare proceedings across the country and conducted more than 200 criminal trials. Many of our attorneys come from senior positions within the Department of Justice and share the experience, insights, and contacts as former federal prosecutors in charge of healthcare matters. While every case varies, the following defense strategies have proven to be most successful for our clients to resolve healthcare investigations without recourse to criminal charges.
- Early Intervention
- Lack of Evidence
- Lack of Intent
- Applicable Defenses
Early Intervention. Early intervention by experienced lawyers is key. Pull the seeds before they grow into a tree. The longer the government investigates uninterruptedly, the higher the chance the case will turn into a criminal matter. Don’t let the government build its case. Hire lawyers with open channels to the government that can immediately initiate a dialogue with their government contacts. Get answers to the most pressing questions: What is the case about? What prompted the investigation? Is the case civil or criminal? What agencies are involved? Who else is under investigation? What is the government’s ultimate goal? How can the issue be resolved? We strive to provide our clients these answers within the first hours of our engagement.
Lack of Evidence. The U.S. justice system places a heavy burden on the government to prove punishable misconduct. In fact, in order to be found guilty of healthcare fraud, the government must prove beyond a reasonable doubt that an illegal act was committed with criminal intent. Our attorneys put this constitutional standard to the test in every single case and we routinely liberate clients from fraud accusations.
- Case Dismissed
- Avoidance of Criminal Charges
- License Maintained
- Civil Fine, No Criminal Plea
- Misdemeanor, No Felony
- No Jail Time
In our experience, we have observed that most incidents that prompt healthcare investigations originate from organizational and human errors, not from criminal spite. Mistakes occur because healthcare providers focus on caring for their patients. Similarly, businesses of interest to the government almost all have rapid growth and fast expansion in common. In either case—patient dedication or business growth—organizational deficits and negligent oversight explain mistakes made. We commonly find these causes for errors:
- Unqualified Staff
- Supervision Errors
- Delegation & Outsourcing
- Structural Deficits
- Organizational Mistakes
- Human Error
- Oversight and Overwhelmed
- Lack of Compliance Program
- Constantly Changing Rules
Lack of Intent. Intentional healthcare fraud is rare and too many business owners are ready to roll over and accept penalties for mere negligent oversight. In a busy practice, mistakes are common and they should not result in fraud convictions or liabilities.
| Anti-Kickback | False Claims Act | Stark Law | Criminal | |
| Offense Nature | Criminal | Civil (& Criminal) | Civil | Criminal |
| Offense Element | Illegal Referrals | False Claims | Self-Referrals | Fraud Scheme |
| Government Burden | Knowing & Willful | Reckless Disregard | Strict Liability | Knowingly |
Applicable Defenses. A thorough analysis often reveals favorable defenses for clients under healthcare investigation. To give you only two recent examples, in a recent Medicare Fraud case that we handled, the government alleged that our client fraudulently certified the need for home healthcare services. We convinced the government that a recognized delegation exception applied rendering the certification fully compliant with the law. In another Medicare Fraud case, we refused to admit liability and ultimately convinced the prosecutors that our client acted within a safe harbor exception.
Oberheiden, P.C.
We represent business owners, healthcare executives, lawyers, healthcare providers, hospitals, pharmacies, laboratories, and other healthcare entities that find themselves under investigation for illegal kickbacks, fraudulent billing practices, and allegations of medically unnecessary services, services not rendered, and unlawful joint ventures between referring physicians and ancillary income businesses.
- Healthcare Fraud Defense
- Compliance Programs
- Internal Investigations
- Qui Tam Defense
- Asset Protection
- Licensure & Disciplinary Proceedings
- Jury Trials
Our clients range from individual providers to entire healthcare systems. We represent clients in Detroit who are under investigation by the Department of Justice, the Department of Defense, the Federal Bureau of Investigation, Drug Enforcement Administration, the Office of Inspector General, the Medicaid Fraud Control Unit, Detroit and Michigan law enforcement, or the Internal Revenue Service.
Our 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 healthcare 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 Healthcare Fraud.
Result: No civil or criminal liability. - Defense of nationally operating healthcare company against an investigation by the Department of Defense for alleged Tricare fraud.
Result: No civil or criminal liability. - Defense of healthcare 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 healthcare 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.
Detroit Defense Attorneys
Dr. Nick Oberheiden is a Harvard-trained and internationally educated healthcare fraud defense attorney. Nick has successfully represented healthcare executives, business owners, public officials, physicians, and lawyers in high profile prosecutions, scores of political corruption, government investigations, and media campaigns, including 60 Minutes. He is most known for stopping federal investigations before criminal charges can be filed. Along with his healthcare defense practice, Nick leads internal investigations, implements corporate compliance programs, and teaches U.S. criminal law and federal litigation in the United States and abroad.
We are available every day of the year, 24 hours a day. You can call, complete our contact form, or email us directly.