Healthcare Law Attorneys

Health care fraud prosecution is a top priority for government law enforcement agencies. During the past several years there have been more agents, cases, indictments, and convictions than ever before. The federal attorneys with Norman Spencer Law Group have years of experience defending healthcare providers in federal criminal cases!

Federal Healthcare Fraud Investigations

If you are a healthcare provider, chances are you work with some of the federally funded healthcare programs such as Medicare and Medicaid. Therefore, you can expect that the federal government will at some point audit your practice. Some of these audits become investigations. Many investigations become prosecutions. Prosecutions may lead to convictions, loss of professional licenses, program exclusions, and just about any other problem you may be afraid of if you are a healthcare provider.

Norman Spencer Law Group federal fraud defense lawyers dedicate themselves to protecting the rights of clients like you. Whether your practice is under an audit or an investigation, we are here to help you, no matter where you are.

With an increase of the growing concern about fraud and abuse, the Office of Inspector General (OIG) is the primary federal agency charged with policing health care providers. They are not alone. The OIG works closely with the Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), private carriers, fiscal intermediaries, and local Medicare and Medicaid Fraud Control Units.

Imagine that the federal government is armed with sophisticated heavy weaponry while health care providers have sticks and rocks if even that. Most providers may not think it’s significant when they are investigated, but the truth is that any interaction with federal law enforcement is as dangerous.

Therefore, we advise healthcare providers to take affirmative steps before an investigation, or as soon as they first realize that there is an investigation to limit their potential liability. Investigations can range from a short call or a letter from a government agency seeking additional information to a full-blown FBI investigation. An investigation can skyrocket from one end to the other really fast. Speak to Norman Spencer Law Group federal lawyers at the first sign that the government has an interest in you.

What Government Agencies Are Involved in Provider Investigations

The list of the government agencies involved in healthcare investigations is long.

Besides Medicare carriers and intermediaries, CMS and its contractors, it includes the Department of Health and Human Services (HHS) through the OIG and the Health Care Financing Administration (HCFA), Department of Defense through the Defense Criminal Investigative Service, the DOJ through the FBI and U.S. Attorney General’s Office, state attorney generals through state Medicaid fraud control units, and others.

What Triggers Healthcare Law Fraud Investigations

There are many potential sources of health care fraud investigations.

Intermediary and Carrier Referrals

Many investigations begin when the carriers and fiscal intermediaries conduct random audits of providers, identify those who submit claims different from those submitted by similarly situated providers, and analyze provider practices in general.

These audits may affect the provider’s business by cutting its cash flow and often result in further review, overpayment requests, or civil monetary penalties. If a carrier or intermediary suspects fraud, they refer the case to the OIG or DOJ.

Here is a typical example we routinely encounter in our defense practice. A provider receives a request from the carrier for medical records. The carrier only requests a small number of records, five to twenty. They say that it is necessary to support the claims recently submitted for payment. This in itself may not necessarily mean trouble. There is no indication that a government investigation is underway. Ideally, if the provider’s records are in good shape and support the services billed, everyone is happy.

Unfortunately, in the real world, the opposite is often true. Designed to be a way of quality control, these requests have become a tool for the carriers to recoup as much money from providers as possible. And because many providers are not good at keeping records to satisfy the requirements, these reviews result in a suspect error rate. The carrier may conduct an additional review, costing the provider dearly, or even refer the matter to the OIG or DOJ.

OIG Audits and Referrals

Another common scenario we see is when the OIG conducts its own review of a provider. The OIG investigates cases of fraud and refers prosecution to the DOJ. The OIG may conduct a review of a provider because of a referral they have received from the carrier or intermediary. In this case, the provider is already suspected of problematic practices.

The law authorizes the OIG to access any records and documents available to HHS, which relate to government-funded health programs. In addition, the OIG routinely issues subpoenas for the production of any documents and evidence.

DOJ/FBI Investigations

The Department of Justice is the major federal agency in the healthcare fraud enforcement scene. It has the Fraud Section with the Health Care Fraud Unit with offices all over the United States. The Unit, also known as the Strike Force, is staffed with federal prosecutors who handle only health care fraud cases. They are responsible for most healthcare-related prosecutions in the US.

Strike Force works together with other agencies such as the FBI, the HHS-OIG, the Centers for Medicare & Medicaid Services (CMS), and essentially all other agencies such as the DEA, the IRS, etc.

Disgruntled Former Employees and Healthcare Law

Many government investigations begin with a report from a disgruntled former employee. This happens more often than most providers think. These former employees have intimate knowledge of the business operations. That makes them quite effective in retaliating against the former employer.

Qui Tam Actions

The False Claims Act prohibits the knowing filing of a false or fraudulent claim for payment by the United States. The False Claims Act is used by the U.S. Attorney General directly, but also through private individuals in a qui tam action. Qui Tam action means that a private party may sue on behalf of the government.

If the qui tam plaintiff prevails, he or she may be entitled to an award of attorneys’ fees and a court-apportioned percentage of the government’s recovery. Employees or individuals with direct knowledge of irregularities have financial incentives to file qui tam actions. The idea is that at some point the government will take over the action and the individual will receive a reward when the case is over.

How Norman Spencer Law Group Can Help with Healthcare Law Cases

Our firm has built a nationwide practice dedicated to protecting healthcare providers. Unlike many other lawyers, our federal defense attorneys are not former prosecutors. All of us have spent years defending cases, not prosecuting them. Defending is a much more difficult job than prosecuting. In the criminal justice system, everything is stacked against the defendant. We used our expertise and tenacity to even the odds.

We employ professionals and experts from every related industry to assist us in providing the best possible healthcare law defense. As a boutique firm based in New York, our federal healthcare practice is nationwide.

If you believe that you are under a federal healthcare law investigation, call us immediately to speak with an experienced criminal defense attorney.