Healthcare providers in New Jersey are actively being targeted in federal Medicare and Medicaid fraud investigations. If your healthcare business or medical practice is under investigation, call (888) 356-4634 to put over 100 years of experience on your side.

Medicare and Medicaid fraud are serious issues that cost taxpayers billions of dollars every year. Federal and state authorities aggressively pursue individuals and organizations suspected of defrauding these important healthcare benefit programs, and large-scale takedowns involving multi-million-dollar fraud schemes are making headlines with increasing frequency.

But in New Jersey and other states around the country, it is not only fraud artists that are getting caught up in Medicare and Medicaid fraud investigations. Authorities such as the Centers for Medicare and Medicaid Services (CMS), the U.S. Department of Justice (DOJ), the Department of Health and Human Services Office of Attorney General (OIG), the Federal Bureau of Investigation (FBI), and the New Jersey Medicaid Fraud Control Unit (MFCU) are targeting legitimate healthcare providers as well, often with devastating consequences.

As a healthcare provider in New Jersey, being targeted in a Medicare or Medicaid fraud investigation (or even an audit conducted by one of CMS’s “fee-for-service” audit contractors) can have enormous legal, financial, and practical implications. If you, or someone within your business or practice, is found to have engaged in fraudulent billing practices, you will be required to repay the overbilled amounts and this is just the tip of the iceberg. In addition to these “recoupments,” providers charged with committing Medicare and Medicaid fraud can also face:

  • Fines of over $21,000 per improper reimbursement request
  • Treble damages (three times the government’s actual losses)
  • Pre-payment review (which can delay Medicare and Medicaid payments by as much as six months)
  • Denial of pending and future Medicare and Medicaid reimbursement claims
  • Exclusion from participation in Medicare and Medicaid
  • Federal imprisonment (up to 5 years for each violation of the law)
  • Professional license suspension or revocation

Can you afford all of these? Can you afford any of them? If your healthcare business is like most, a Medicare or Medicaid fraud investigation could be the end of the road unless you do what it takes to defend yourself successfully.

Medicare and Medicaid Fraud Defense Lawyers Serving All of New Jersey

The healthcare fraud defense lawyers at Oberheiden, P.C. are committed to helping protect Medicare and Medicaid providers in New Jersey. With a national reach practice and locations across the country, our goal is to protect our clients against the severe consequences of Medicare and Medicaid fraud audits and investigations. From resolving investigations without charges (which we are able to do in a significant number of cases) to dismissing indictments and avoiding prison time at trial, we do what it takes at each stage of the process and we do not rest until our clients business, personal assets, and freedom are secure.

“We have never dealt with legal counsel who is so down to earth and compassionate toward his clients. [Dr. Nick Oberheiden] has a level of compassion and dedication that one would only expect from a family member. He is responsive and has even worked with us on weekends . . . . [I]f we could afford to pay him more than his requested fee, we would have, due to his dedication, compassion and competence. In a situation where we felt like there was little hope, this gentleman provided a bright light at the end of a dark tunnel. There is no one better and if you are seeking a Federal Criminal Attorney, you can’t go wrong with this gentleman. He has a heart for what he does that we don’t often see in today’s legal profession.”  Katy, Firm Client
“It is very clear to me that Nick Oberheiden has a deep understanding of health law issues. Nick has been instrumental in managing and resolving many difficult legal matters. He is always relentlessly focused on the critical issues that matter most. Nick is very dedicated and available and always displays a high degree of professionalism. I would not hesitate in recommending Nick for the most important of legal matters.”  Chris, Firm Client

Our Areas of Practice

With a practice devoted to healthcare fraud defense, we represent New Jersey providers in all matters pertaining to Medicare and Medicaid audits and investigations. Due to the extreme risks involved, as soon as you are contacted by an auditor or federal agent, it is strongly in your best interests to seek experienced legal representation. Once you contact us, we can take action immediately. This includes making contact with the authorities involved in your case to learn the scope of the investigation and let them understand that you are represented by counsel.

We represent New Jersey healthcare providers and businesses in the healthcare industry in matters including all of the following actions.

Medicare and Medicaid Audits

Many healthcare providers get their first introduction to the government’s Medicare and Medicaid enforcement regime through CMS’s “fee-for-service” audit recovery program. Under this program, private contractors working with CMS are endowed with the authority to audit providers that bill Medicare and Medicaid for reimbursements. If your practice bills one of these healthcare benefit programs, you are required to submit to these contractor audits.

Although an “audit” may not seem all that intimidating, it is important to understand exactly what it means to be audited under CMS’s “fee-for-service” audit recovery program. CMS’s audit contractors get paid to uncover overbillings to Medicare and Medicaid. When they uncover overbillings they can impose penalties including (but not limited to) recoupments and pre-payment review. They can also refer providers to CMS, the DOJ, and other federal authorities for investigation and prosecution. Unfortunately, it is not unusual for an unfavorable audit determination to eventually lead to federal charges.

At Oberheiden, P.C. we represent New Jersey providers in audits conducted by all Medicare and Medicaid audit contractors, including:

  • Zone Program Integrity Contractors (ZPICs)
  • Recovery Audit Contractors (RACs)
  • Medicare Administrative Contractors (MACs)
  • Audit Medicaid Integrity Contractors (MICs)

Medicare and Medicaid Audit Appeals

If it is too late to avoid an unfavorable audit determination, our attorneys can guide you through the Medicare and Medicaid audit appeals process. There are five stages of appeals, each with its own unique deadlines, requirements, and standards of proof. Pursuing a successful appeal requires an in-depth understanding of the laws, processes, and procedures involved. Our attorneys have decades of combined experience representing clients at each level of appeal, and we can use our experience to help you challenge flawed auditing methods and conclusions. The five stages of appeal for Medicare and Medicaid audit appeals are:

  • Request for Redetermination
  • Request for Reconsideration
  • Administrative Appeal with the Office of Medicare Hearings and Appeals (OMHA)
  • Administrative Appeal with the Medicare Appeals Council
  • Civil Appeal in Federal District Court

OIG and Grand Jury Subpoenas

OIG and grand jury subpoenas are very different, but they can both lead to the same outcome: charges for Medicare or Medicaid fraud in federal criminal court. An OIG subpoena is an investigative tool that the Office of Inspector General uses to gather information from providers suspected of engaging in fraudulent activities. The Office of Inspector General can issue an OIG subpoena without the need to seek court approval, and these subpoenas which are often extremely broad can only be challenged under very limited circumstances. As a result, providers that receive OIG subpoenas should generally be prepared to comply fully with their subpoenas demands. However, they also need to be careful to avoid mistakes that could trigger further government inquiry.

In contrast, a grand jury subpoena is a tool that prosecutors use to determine whether or not to issue an indictment. When subpoenaed to appear before a grand jury, you must provide documents or testimony (or both) so that the government can determine if there is probable cause to pursue a case against you. You can be subpoenaed in your individual capacity or as a representative or “custodian” of your business, and a grand jury subpoena can lead to either civil or criminal charges.

False Claims Act Investigations

The False Claims Act (FCA) is a broad federal statute that prohibits any and all “false and fraudulent” claims for payment from the government. This includes requests for reimbursement through Medicare and Medicaid, and most providers targeted in federal investigations will be targeted under the FCA (potentially in addition to a variety of other federal statutes as well).

The False Claims Act includes provisions for both civil and criminal penalties. Most FCA investigations targeting legitimate healthcare providers start out civil; and if at all possible, you want to prevent your investigation from becoming criminal in nature. At Oberheiden, P.C., we have a significant track record of protecting clients in civil False Claims Act investigations, and to date not a single client of ours has faced criminal charges or penalties as the result of an FCA investigation.

Stark Law and Anti-Kickback Statute Investigations

The Stark Law and Anti-Kickback Statute are federal laws that prohibit payment of referral fees and other forms of remuneration in connection with Medicare and Medicaid-reimbursed services, supplies, and equipment. While the Stark Law applies specifically to physicians and their related entities, the Anti-Kickback Statute applies to all types of healthcare businesses and practices, including:

  • Home Health and Hospice Centers
  • Hospitals & Surgery Centers
  • Marketing Groups
  • Medical Device and Durable Medical Equipment (DME) Companies
  • Pharmacies (including Compound Pharmacies)
  • Physician-Owned Entities
  • Toxicology Laboratories

Violations of the Stark Law or the Anti-Kickback Statute can result in penalization under the False Claims Act. And while the Stark Law includes provisions for civil penalties only, providers investigated under the Anti-Kickback Statute can face both civil and criminal prosecution.

Other Medicare and Medicaid Fraud Investigations

If you have just discovered that your business or practice is under investigation, there is a good chance that you do not understand why you are being investigated much less the specific statutes that you have allegedly violated. Keeping this information from you provides investigators and prosecutors with the upper hand; and for this reason, one of our first steps when you engage us will be to determine the nature of the government’s inquiry.

While most Medicare and Medicaid fraud investigations involve the False Claims Act, Stark Law, and/or Anti-Kickback Statute, there are numerous other statutes that could potentially be involved in your investigation as well. Once we gather information about the specific allegations against you, then we can build and execute a defense strategy designed to protect you as quickly and cost-effectively as possible.

Civil and Criminal Healthcare Fraud Prosecutions

In certain circumstances, it simply is not feasible to avoid prosecution. If the facts are not on your side, prosecutors will press charges, and they will work to build the strongest possible case and obtain a conviction at trial. At Oberheiden, P.C., all attorneys on our healthcare fraud defense team are highly-experienced litigators. Whether you are being forced to defend your actions in civil or criminal court, we can use our prior experience (including experience as federal healthcare fraud prosecutors) to aggressively pursue a trial strategy focused on securing the best possible outcome.

Answers to FAQs: Facing Medicare and Medicaid Audits and Investigations in New Jersey

Q: I didn't do anything wrong on purpose. Can I still be charged with Medicare or Medicaid fraud

Unfortunately, yes. Under the False Claims Act, Anti-Kickback Statute, and various other laws, state and federal prosecutors have the option to pursue civil or criminal charges. While criminal cases require evidence of intent, you can be prosecuted civilly even for an unintentional violation. In fact, most Medicare and Medicaid fraud cases involving legitimate healthcare providers are civil in nature precisely because evidence of intent is not required.

When you contact us about your Medicare or Medicaid fraud investigation, one of our first steps will be to conduct an internal assessment. In short, we need to understand if you did anything wrong before the government reaches its own conclusion. If it appears that you (or one of your staff members) have made a mistake, we will work with you to enhance your compliance program and proactively address the issue in the best way possible to mitigate your potential liability.

Q: What are some examples of billing violations that can be prosecuted civilly or criminally as Medicare or Medicaid fraud

Typically, Medicare and Medicaid fraud investigations focus on healthcare providers billing practices under these healthcare benefit programs. Avoiding liability is often an exercise in disputing the authorities data-based assumptions, and demonstrating that billing practices which may sometimes be indicative of fraud (and which may look like fraud to the government’s data analytics software) are actually fully-legitimate in light of a particular provider’s unique practice or patient demographics. Some of the most-common allegations against healthcare providers include:

  • Billing for medically-unnecessary services

  • Billing for services not provided

  • Unbundling

  • Upcoding

  • Payment and receipt of kickbacks and referral fees

  • Pharmaceutical fraud

  • Physician certification fraud

Q: Why is a company called CGS Administrators, Noridian, or Novitas demanding information about my business's or practice's program billing records

CGS Administrators, Noridian, and Novitas are the Medicare Administrative Contractors (MACs) currently assigned to conduct audits in New Jersey. If you have been contacted by one of these companies, this means that your business or practice is being audited for Medicare billing compliance. In order to avoid disclosing more information than necessary and prevent flawed audit practices from jeopardizing your ability to serve your patients, it is critical that you speak with an attorney as soon as possible.

Q: What is the New Jersey Medicaid Fraud Control Unit (MFCU)?

The New Jersey Medicaid Fraud Control Unit (MFCU) is an office within the New Jersey Office of the Insurance Fraud Prosecutor that is tasked with combatting healthcare fraud targeting the Medicaid program. As stated on the MFCU’s website, its goal is to investigate and prosecute:

  • “Healthcare Providers who are suspected of defrauding the Medicaid Program;

  • “Fraudulent activities by providers against the Medicaid program;

  • “Fraud in the administration of the program;

  • “Fraud against other federally funded healthcare programs where there is a Medicaid nexus;

  • “Complaints of patient or resident abuse or neglect in healthcare facilities receiving Medicaid funding such as nursing homes [and] those Medicaid beneficiaries who reside in any other setting outside their home where care is provided to them. Abuse and/or neglect means both physical abuse or neglect and fiscal pertaining to money or property abuse or neglect; [and,]

  • “Violations of the Civil False Claims Act, where the alleged fraud impacts Medicaid.”

In many cases, the New Jersey MFCU works in conjunction with the federal Medicare Fraud Strike Force and other authorities to pursue civil and criminal charges against providers suspected of defrauding multiple government healthcare benefit programs.

Contact the Healthcare Fraud Defense Team at Oberheiden, P.C.

If your business or practice is under investigation in New Jersey, we urge you to contact us immediately to discuss your case. To speak with the attorneys on our healthcare fraud defense team in confidence, please call (888) 356-4634 or inquire online now.

This information has been prepared for informational purposes only and does not constitute legal advice. While this information may constitute attorney advertising in some jurisdictions, merely reading this information does not create an attorney-client relationship. Every case is different, any prior result described or referred to herein cannot guarantee similar outcomes in the future. Oberheiden, P.C. is a Texas limited liability partnership with its headquarters in Dallas, Texas. The attorney on record limits his practice to federal law.