Healthcare Fraud Attorneys

Healthcare fraud encompasses a broad scope of conduct aimed at criminalizing fraudulent acts of professionals and businesses in the healthcare industry.  The majority of healthcare fraud cases stem from the fraudulent billing of Medicare or a state insurance program.  Most doctors and healthcare businesses accept Medicare and state insurance from patients.  By doing so, they promise to follow the extensive rules and regulations within those systems.  These rules and regulations are incredibly complex.  This complicated framework often provides pitfalls for professionals, but also, provides legitimate defenses to criminal charges.  As a general rule, the more difficult the law is to understand, the easier it is for your healthcare fraud attorneys to challenge the willfulness element present in all healthcare fraud prosecutions.

How Do I Know If I am Under Investigation for Healthcare Fraud?

As with most federal investigations, a healthcare fraud investigation normally starts with the target physician or medical professional being contacted by the federal government.  This contact can occur via a government issued subpoena for records, a grand jury subpoena requesting testimony, or a target letter advising the professional they are under investigation.  When contact is made, it is imperative that the target reach out to a healthcare fraud attorney to ensure proper steps are being taken.  Early in a criminal investigation, there may be opportunities to pull the criminal probe back under the civil umbrella.  Or potentially side step the government action altogether.  As the government spends resources on the investigation, it becomes less likely they will drop their focus.  It is important to note that not every criminal investigation can be stopped, but when they are, it is early in the process.

How Do Healthcare Fraud Investigations Start?

Healthcare fraud investigations normally start one of three ways: 1) the physician or biller is a large outlier under certain service or product codes, 2) the case is referred in a parallel investigation or 3) a patient or colleague alerts federal authorities.  All three of these routes are very common ways to give berth to a federal investigation.  The government is always tracking physicians, labs, and other professionals that bill their programs in hopes of avoiding unneccessary waste.  

What Actions Lead to a Healthcare Fraud Investigation?

It is important to note that healthcare fraud in the United States is tied to the improper billing of Medicare or a government backed program.  The federal government does not go after doctors for practicing bad medicine or making mistakes in private practice.  Those issues are left to state prosecutors, state civil courts, and state licensing boards.  The federal government launches criminal investigations into physicians and other medical professionals who charge Medicare outside of the federal regulations that were put in place to avoid waste.

The most common schemes our healthcare fraud attorneys see in practice are: 1) billing for unneccessary services, 2) using improper billing codes to elevate claims, 3) billing for products or services that are not rendered, 4) paying illegal remuneration for service referrals (kickbacks), and 5) technical regulatory violations that trigger higher payouts (violations of supervision provisions or qualifications). There is a broad swath of conduct that falls under these general headings, but these areas cover over 90% of federal healthcare fraud investigations in the United States.

How do you Defend Yourself Against Healthcare Fraud Allegations?

There are two main goals for our clients under a healthcare fraud investigation: 1) avoiding a conviction/jail time and 2) saving their license for continued practice.  With these goals in mind, it is imperative that the target of a healthcare fraud investigation reach out to competent counsel early in the process.  Both of the above goals can be met if the attorneys can steer the investigation back under the civil umbrella.  The best outcomes, considering financial and collateral impacts, occur during the investigation phase.  Having said that, derailing an investigation takes a concerted effort.  For the government to let go of a criminal cause of action, they need to believe they could lose the case at trial.  This requires a healthcare fraud attorney to build a defense early in the process to have a chance at avoiding criminal litigation.

All healthcare fraud charges are going to involve interpretations of professional judgment, proper billing procedures, and insight into the physician’s state of mind when the claims were submitted.  It is not illegal to submit a claim to Medicare that is false.  To prove a criminal case, the government must show the physician or medical professional knew the claim was improper before it was submitted.  Mistakes, accidents, or a misunderstanding of the rules is not a criminal act.  This reality combines with complexities in the regulations to allow unique and powerful defenses in some cases.  If those defenses can be built early in the process, they can be used to make the government uncomfortable with their case.  This lack of comfort can provide the uncertainty needed to resolve the matter civilly, and hopefully, meet the two main goals for the client.

Can you Beat a Healthcare Fraud Charge at Trial?

Each healthcare fraud case is different.  There are cases where the pattern of conduct is so pervasive that the chances of winning at trial are very small.  This is true whether you hire a respected healthcare fraud attorney or get court appointed counsel after charges are filed.  Having said that, there are a significant percentage of cases where a true defense does exist.  In those cases, the defense must be prepared through the use of coding experts, industry leaders, scientists, and other expert witnesses to develop the foundation for the client’s story.  If the foundation can be adequately built, these cases provide fertile grounds for winning at trial.

Every healthcare fraud trial we have won had the same recipe.  We had better experts than the government on the seminal issues at trial and our client was able to deliver a compelling story to explain his/her actions.  Most cases that make it to trial are going to have claims that were billed incorrectly.  Healthcare fraud trials are not about proving the medical professionals’ actions were correct under the law.  It is about persuasively convincing a jury that the physician believed the claims were proper when submitted.

Odom, Davis & Hobson – Healthcare Fraud Case Results

In 2019, our firm was hired to represent a physician charged with health care fraud – billing for medically unnecessary procedures.  The government alleged the client fraudulently billed Medicare for over $65 million dollars.  The case went to trial in January of 2020.  After two months of litigation, the judge found our client not guilty on all 25 counts alleged in the indictment.  The client kept his medical license and continued in his occupation. An in depth review of the issues in that case and the defense that was built can be found in the healthcare fraud defense blog below.

We have successfully represented numerous doctors, nurses, and medical professionals under investigation for healthcare fraud.  We have closed these cases down in the investigation stage, and our trial record is as good as it gets.  There are only a handful of firms in the country that have obtained not guilty verdicts on large federal healthcare fraud schemes.  

If the government is investigating a healthcare fraud related matter, do not hesitate to contact us.  We are prepared to help any professional through this process.  If you do not hire us, hire someone like us.  There is too much on the line and you need to hire competent healthcare fraud attorneys to ensure a good result.

Our attorneys write various articles related to healthcare fraud defense.  Those articles can be found at the Healthcare Fraud Defense Blog.