The health care fraud defense team at Oberheiden, P.C. brings over 100 years of experience to representing Pennsylvania providers in Medicare and Medicaid fraud matters. Whether you are facing an audit, investigation, or federal charges, we can help protect your business or practice with the goal of securing your future.
For health care providers in all parts of Pennsylvania, Medicare and Medicaid compliance are facts of life. Your patients rely on these benefit programs, which means that you rely on these benefit programs. This means that you need to maintain a comprehensive compliance program in order to avoid submitting improper claims for reimbursement.
As the Medicare and Medicaid systems have grown in both size and complexity, maintaining compliance has become an even more significant burden. For providers of all sizes and in all segments of the health care industry, making sure you code and bill your services and supplies appropriately is a job unto itself. It is also a burden that carries significant repercussions, as providers that make mistakes (even despite their best efforts at compliance) are increasingly being hit with recoupments, fines, and other penalties.
An Experienced Health Care Fraud Defense Team Fighting for Pennsylvania Providers
At Oberheiden, P.C., our practice is devoted to fighting for health care providers in Pennsylvania and nationwide. With a team that includes former state and federal health care prosecutors, we are greatly positioned to defend providers against allegations of Medicare and Medicaid fraud, waste, and abuse. We know the government’s tactics – because we helped develop them. As a result, we know what it takes to protect providers against the consequences of invasive audits and investigations.
If your health care business or practice is being targeted in an audit or investigation, it is critical that you engage legal counsel. You need to make sure you that deal with the auditors, agents, and prosecutors involved in your case appropriately, and you need to execute a comprehensive defense strategy focused on the specific allegations against you. But first, you need to know what you are up against, and even this can be a challenge. With decades of experience on both sides of Medicare and Medicaid fraud cases, our attorneys can quickly determine the scope and nature of the government’s case, and we can work with you to formulate a defense strategy that gives you the best possible chance to avoid civil and criminal liability.
Many health care providers are shocked to learn that they can face felony charges for Medicare and Medicaid billing violations. The False Claims Act and various other laws impose severe penalties for all forms of health care fraud, and violations that are deemed to be intentional can lead to criminal prosecution. In Medicare and Medicaid fraud matters, our first priority is always to keep our clients’ cases civil in nature. If we can keep your case civil, you will not be at risk for going to prison, and this will allow us to focus our efforts on mitigating your financial liability – if not avoiding financial liability entirely.
A Comprehensive Approach to Medicare and Medicaid Fraud Defense
We take a comprehensive approach to Medicare and Medicaid fraud defense which focuses on securing the best possible result at each stage of the process. While our goal is always to resolve our clients’ audits and investigations as quickly as possible, we also keep an eye toward the future, and we are constantly strategizing to stay one step ahead of the government.
1. Challenging Flawed Assumptions and Methodologies in Audits and Investigations
Auditors and investigators make mistakes, and exposing these mistakes can be critical to avoiding unwarranted consequences. From making flawed assumptions based upon limited information to applying outdated Medicare and Medicaid billing regulations, we have the experience to spot and rectify the issues that can lead to unjustified demands for recoupments and future reimbursement denials.
2. Avoiding Civil and Criminal Charges
If you aren’t charged, you won’t go to trial. In every case, we work tirelessly to help our clients avoid civil and criminal charges. If we can raise enough questions about the government’s case, we can protect you from the risk of facing civil liability or criminal penalties.
3. Dismissing Federal Indictments
Even once an indictment has been issued, our focus remains on resolving your case prior to trial. While this may mean negotiating a plea deal, we have also had success convincing federal prosecutors to dismiss our clients’ charges and undo their indictments.
4. Presenting Exhaustive Defense Strategies at Trial
We never recommend a bad plea deal. If going to trial is your best option, we will prepare meticulously and fight vigorously to protect you from a guilty verdict in court. With our extensive experience, we understand when it is time to shift our focus from convincing the U.S. Attorney’s Office to convincing the judge or jury, and our health care fraud defense team is comprised of veteran litigators who have proven records of success at trial.
5. Arguing for Minimal Sentencing
If there is simply no way around a guilty verdict, we will do everything in our power to minimize your sentence to the greatest extent possible. We have obtained probation for clients who were facing years of federal imprisonment; and to date, not a single client of ours has been forced to close its business or practice as the result of an investigation that we handled.
Your Defense Team for All Medicare and Medicaid Fraud Matters in Pennsylvania
Whether you have just learned that you are being audited or investigated, you have received a demand for recoupment following an audit, or you have been detained on charges of Medicare or Medicaid fraud, our health care fraud defense lawyers can help you. Contact us now for a free consultation about your case involving any of the following.
- ZPIC, RAC, MAC, or MIC Audit – Zone Program Integrity Contractors (ZPICs), Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Audit Medicaid Integrity Contractors (MICs), and other auditors operating under the Centers for Medicare and Medicaid Services’ (CMS) “fee-for-service” recovery program can demand recoupments, deny payments, institute pre-payment review, and trigger other sanctions for alleged billing violations. Health care providers need to take these audits just as seriously as federal investigations.
- Demand for Recoupment – If you have already received a demand for recoupment as a result of an unfavorable audit determination, you will need to challenge the demand through the formal appellate process. There are multiple stages of appeal for CMS contractor audits, culminating with a review in federal district court.
- OIG Subpoena – The U.S. Department of Health and Human Services Office of Inspector General (OIG) uses administrative subpoenas (or “OIG subpoenas”) to gather information from targets of Medicare and Medicaid fraud investigations. These subpoenas can be extraordinarily broad and they are notoriously difficult to challenge, and providers who have received OIG subpoenas must begin preparing an appropriate response immediately.
- Grand Jury Subpoena – If you have received a grand jury subpoena, this could mean that you are being targeted in a federal investigation, or it could mean that prosecutors believe you have information about another provider that is suspected of engaging in Medicare or Medicaid fraud. In either case, failing to respond appropriately can have dire consequences, and you need to be careful to avoid mistakes that could expose you to liability.
- False Claims Act Investigation – False Claims Act (FCA) investigations can be either civil or criminal in nature, and they can target any and all forms of alleged Medicare and Medicaid billing violations. Some of the most common allegations of “false and fraudulent claims” in FCA investigations include: upcoding, unbundling, double-billing, billing for medically-unnecessary services, and billing for services not actually performed.
- Kickback or Referral Fee Investigation – Illegal kickbacks and referral fees are common allegations in False Claims Act investigations as well. These allegations can also trigger liability under the Stark Law and Anti-Kickback Statute, which are federal statutes that apply specifically to health care providers. The Stark Law imposes civil penalties for “physician self-referrals,” while the Anti-Kickback Statute includes both civil and criminal provisions and applies to all types of providers.
- Other Medicare or Medicaid Fraud Investigation – Allegations of Medicare and Medicaid fraud can lead to charges under a broad range of other federal and Pennsylvania statutes as well. In addition to laws that are specific to the health care industry, providers targeted in Medicare and Medicaid fraud investigations will frequently also be charged under general criminal laws outlawing conspiracy, money laundering, mail fraud, wire fraud, and other related offenses.
- Civil or Criminal Charges for Medicare or Medicaid Fraud – If you have been arrested and charged with Medicare or Medicaid fraud in Pennsylvania, you need to engage legal counsel immediately. You could be facing hundreds of thousands, if not millions of dollars in financial liability; and if you have been charged criminally, you could be facing years or decades of federal incarceration.
Frequently-Asked Questions (FAQs) about Defending Against Medicare and Medicaid Fraud Allegations in Pennsylvania
Q: What is the Pennsylvania Medicaid Fraud Control Section (MFCS) and why is it contacting me?
The Pennsylvania Medicaid Fraud Control Section (MFCS) is a division of the Attorney General’s Office that dedicates its resources to combatting fraud, waste, and abuse affecting the state’s Medicaid system. According to the MFCS website, its “main focus” is on targeting providers suspected of defrauding Medicaid, including:
- Mental health clinics
- Drug and alcohol clinics
- Health maintenance organizations (HMOs)
Similar to the federal Medicare Fraud Strike Force (which is a joint operation of the U.S. Department of Justice (DOJ) and other agencies), the MFCS has broad investigative and prosecutorial authority, and its investigations can lead to a broad range of civil and criminal charges. “Along with the original jurisdiction to prosecute and investigate Medicaid fraud, the Commonwealth Attorneys Act gives the [Attorney General’s Office] the authority to investigate crimes arising out of the activities of the MFCS. This enables investigators to follow the leads generated by their investigations to other violations of the Pennsylvania Crimes Code.”
Q: Why is a company called CGS Administrators, Noridian, or Novitas demanding my business’s billing records? Do I need to comply with these demands?
CGS Administrators, Noridian, and Novitas are audit contractors operating under CMS’s “fee-for-service” audit recovery program in Pennsylvania. As a Medicare or Medicaid participant, your business or practice is subject to regular audits of its billing records; and generally speaking, you need to be cooperative during the audit process.
However, this does not mean that you need to give the auditors everything they demand. It also does not mean that you need to go along with the auditors’ methodologies and conclusions. Mistakes during Medicare and Medicaid audits do occur; and as a result, providers need to hire legal counsel to intervene in the process and address any issues that may lead to unjustified liability.
Q: What types of compensation arrangements are permitted under the Stark Law and Anti-Kickback Statute?
The Stark Law and Anti-Kickback Statute are unique in that they contain extraordinarily-broad prohibitions which are then scaled back through a laundry list of statutory and regulatory safe harbors and exceptions. As a result, when facing a Stark Law or Anti-Kickback Statute investigation, the onus often falls on the provider to affirmatively demonstrate that their compensation arrangement qualifies for exemption from prosecution. Some of the most-commonly-used safe harbors and exceptions include those that apply to:
- Specific types of providers, such as ambulatory surgery centers and cooperative health service organizations
- Bona fide employment relationships
- Fair market value compensation, physician services, and personal service arrangements
- Incidental benefits for medical staff
- In-office ancillary services
- Indirect compensation arrangements
- Isolated transactions
- Price reductions, professional courtesy, and certain types of referral fees
- Waivers of coinsurance and deductibles
- Insurance subsidies, rental for office space or equipment, and other qualifying expenses
Q: Can health care providers face multiple charges for Medicare or Medicaid fraud?
Yes. In fact, this is common. As an example, if you are being accused of offering, paying, soliciting, or accepting an illegal kickback or referral fee, you could be charged under the Anti-Kickback Statute and the False Claims Act. If your case results in federal prosecution, you will likely also be charged with conspiracy (since kickback and referral fee arrangements inherently involve more than one party), mail fraud or wire fraud (since you necessarily must have communicated with another party), and potentially a variety of other federal offenses as well.
Q: What are some more examples of billing and coding violations that can be prosecuted as Medicare and Medicaid fraud?
In addition to the violations we listed above (upcoding, unbundling, double-billing, billing for medically-unnecessary services, and billing for services not actually performed), other common allegations in Medicare and Medicaid fraud investigations include:
- Billing for non-allowable costs (costs which are not eligible for Medicare or Medicaid reimbursement)
- Billing for services provided by an unlicensed or excluded physician (seeking reimbursement for services rendered by an in-house or third-party physician who is not eligible for participation in Medicare or Medicaid)
- Non-compliance with conditions (failing to meet the requirements for obtaining Medicare or Medicaid reimbursement)
- Physician certification fraud (submitting or relying upon an invalid certification for home health or hospice care services)
- Use of improper billing codes (even if you provide a reimbursable service, you can be charged with fraud if you submit the wrong billing code)
Q: What are the penalties for Medicare and Medicaid fraud?
Under federal law, the potential penalties for Medicare and Medicaid fraud include fines, recoupments, treble damages (three times the government’s actual losses), program exclusion, and imprisonment. The specific penalties you are facing will depend on the statutes under which you are being prosecuted and whether your case is civil or criminal in nature (imprisonment is a criminal penalty, and the financial penalties vary in civil and criminal cases as well). If you are charged with Medicaid fraud under Pennsylvania law, you can face similar penalties.
Contact Oberheiden, P.C. | A National Reach Health Care Fraud Defense Law Firm
The health care fraud defense team at Oberheiden, P.C. has a significant record of successfully defending providers in Medicare and Medicaid fraud cases across the country. If you are facing an audit, investigation, or prosecution in Pennsylvania, we can act quickly to intervene in the case and assemble a comprehensive defense strategy. To get started with a free and confidential consultation, call us at (888) 356-4634 or inquire online now.