Los Angeles & Southern California Healthcare Fraud Defense Attorneys

Los Angeles and Southern California where Chapman Law Group practices healthcare law.

What to Know About Federal Healthcare Fraud Charges

If you’re a Los Angeles- or Southern California-based physician, pain management specialist, pharmacist, nurse, or chiropractor, and you receive a grand jury subpoena or are contacted by a federal agent for a healthcare fraud investigation, your whole career is at stake.

You could be facing more than just hundreds of thousands of dollars in fines and decades of prison time. You also could lose your license. Your business and personal property could be in forfeiture.

Everything you’ve worked so hard for could be swept away.

This situation has become all too common in Southern California. Considering the diversity and density of populations in and around Los Angeles, the region is fertile ground for federal healthcare fraud prosecutions. It has one of the highest rates of federal healthcare fraud indictments in the country — so much so that, since 2010, the U.S. Department of Justice (DOJ) has operated a “strike force” to prosecute healthcare fraud in and around L.A.

Healthcare fraud — including Medicare fraudMedicaid fraud, and TriCare fraud — has been the main target of federal prosecutors in recent years. That focus has led prosecutors to charge weaker cases, while hoping that overwhelmed defendants and inexperienced attorneys will fail to see those weaknesses.

If you find yourself accused of healthcare fraud, there is no time to delay. Any action you take could affect you and your family for years to come.

But first, you need to know what healthcare fraud is all about, how investigations take place, and the paths cases can go.

What is Health Care Fraud?

Healthcare fraud is a type of white-collar crime that involves the filing of fraudulent healthcare claims. This can include anyone who bills or causes a bill to be submitted to Medicare, Medicaid, TriCare, or an insurance company. A false claim may include billing for services that have not been performed, billing for something medically unnecessary, upcoding, and using improper CPT codes.

Medical fraud cases, like most federal crimes, involve deceit, concealment, and violation of trust. They are not dependent on the threat of physical force or violence. 

The breadth of that definition allows the government to charge any person that it believes it can prove: 

    • devised a scheme or artifice;
    • to defraud a healthcare benefit program; and
    • that the scheme was executed.

The government must prove all three factors beyond a reasonable doubt.

Many attorneys who do not specialize in healthcare fraud are unaware that violations of billing requirements, such as local coverage determinations (LCDs) or national coverage determinations (NCDs), are insufficient, alone, to satisfy this requirement.

Despite this fact, the government and the Department of Justice (DOJ) Healthcare Fraud Strike Force continuously charge healthcare providers with healthcare fraud charges for differences of opinion related to the practice of medicine or pharmacy. These include:

    • Exceeding opioid prescribing guidelines
    • Exceeding urinalysis testing guidelines
    • Exceeding guidelines for back injection
    • Improper entries into medical records
    • Upcoding
    • Unbundling
    • Billing improper CPT Codes (99211-5)

The DOJ Healthcare Fraud Strike Force has operations in major cities across the U.S, including Chicago, Dallas, and Philadelphia.

What Are the Most Common Healthcare Fraud Crimes?

    • Accepting kickbacks for patient referrals. The Federal Anti-Kickback Statute (AKS) prohibits offering or providing anything of value to induce the referral of Medicare or Medicaid business.
    • Submitting false or inflated claims to federal healthcare programs such as Medicare, Medicaid, and TriCare, as well as third-party insurance carriers (UnitedHealthcare, Blue Cross Blue Shield).
    • Billing for services or durable medical equipment not provided.
    • Billing for more expensive services or procedures than were actually provided or performed.
    • Physician self-referral (Stark Law).
    • Performing medically unnecessary services solely for the purpose of generating insurance payments.
    • Making false statements on applications or contracts to participate in Medicare or Medicaid programs.
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How Does a Federal Health Care Fraud Investigation Begin?

Most federal healthcare fraud investigations begin through audits, whistleblower tips (also known as Qui Tam matters), or patient complaints.

Virtually everyone is familiar with the FBI, but few are aware of the Department of Health and Human Services’ Office of the Inspector General (HHS-OIG). The OIG is the nation’s leading law enforcement agency for investigating healthcare fraud. Its focus is to protect beneficiaries and federal healthcare programs such as Medicare, Medicaid, and TriCare. More times than not, the OIG is leading the healthcare fraud investigation, working directly with the prosecutors from the U.S. Attorney’s Office.

When it comes to auditing, the Centers for Medicare & Medicaid Services (CMS) and HHS review statistical data generated from Medicare and Medicaid bills to look for outliers. Once the OIG or CMS finds an outlier, it typically conducts an audit and, in severe cases, may immediately refer a case for criminal prosecution.

During an audit, HHS will obtain billing records and request medical records. An initial audit may require review of only a few files, often called a probe audit.

If fraud is suspected after an audit, the case will be referred for investigation and prosecution. When the case is referred, federal law enforcement agents will begin investigating the billing data and interviewing witnesses in order to prepare a case.

Once the case is prepared, an attorney from a local U.S. Attorney’s Office or the Healthcare Fraud Strike Force will prepare an indictment and take a case to a grand jury. If the grand jury returns an indictment, the subject of that indictment will be charged with healthcare fraud and will be required to defend that indictment in court.

How is Healthcare Fraud Prosecuted?

Healthcare fraud is usually prosecuted by the U.S. Attorney’s Office in the DOJ and the DOJ Healthcare Fraud Strike Force, as a violation of federal law. There are criminal charges specifically aimed at healthcare professionals:

In addition, California has its own Anti-Kickback Statute.

A typical healthcare fraud indictment will charge one overarching count of conspiracy to commit healthcare fraud, along with several “substantive” counts alleging individual executions of the scheme. Money laundering charges and forfeiture charges also commonly appear in these indictments.

The conspiracy charge is one of the government’s favorite prosecutorial tools in healthcare fraud cases, as it only requires that the government prove an agreement to commit healthcare fraud and an act in furtherance of the scheme.

The Government will also seek to seize significant assets from a healthcare fraud defendant, in an effort to keep the defendant from being able to marshal the funds to mount a successful defense.   

Healthcare fraud may also be prosecuted in relation to a healthcare professional’s prescribing habits under the Controlled Substances Act (CSA). The government relies on vague requirements that a provider violates the CSA when a controlled substance is not prescribed for a legitimate medical purpose, and when the prescriber is acting outside his/her usual course of professional practice. These terms are not clearly defined and are very subjective.

When Should I Contact a Healthcare Fraud Defense Attorney?

You should be concerned the minute you receive a subpoena or a federal investigator asks to speak to you about a healthcare investigation. When investigators reach out to speak with someone, the investigation itself has been active for a long time. They already have their strategy drawn out, and they know what they are looking for.

They want you to talk. They want you to tell your story — without a lawyer. Without any lawyer, let alone a Medicare fraud attorney.

You can’t afford to fall into that trap.

The moment you receive a target letter from the DOJ or are contacted by federal agents is a good time to consult a Los Angeles/Southern California health care fraud defense attorney. By developing a defense strategy while the case is still in the investigatory stage, there is a better chance of resolving the case before any formal charges are filed.

How Should I Be Prepared for Questioning by Federal Agents?​

You have to keep in mind that federal investigators have received the best training in the world on questioning and interrogation techniques. Most people don’t realize that the psychological manipulation has begun before the first question is even asked.

Sometimes it really is like the “good cop/bad cop” scenario in the movies and on TV. The bad agent will be aggressive, make accusations, and be threatening; the good agent will act like your friend who is sympathetic and understanding, trying to help you out, and defending you from the bad cop. They want you to “clear something up” or ask you to explain some “small mistakes” or “minor inconsistencies” found in an audit.

It’s not a fair fight for you to speak to investigators by yourself. The only way to be truly prepared for questioning by federal agents is to be represented by an experienced Los Angeles/Southern California Medicare fraud defense lawyer.

What Does It Mean to Be Indicted for Healthcare Fraud?

An indictment is the formal start to a healthcare fraud prosecution. A grand jury is presented with evidence and makes the decision over whether to issue an indictment, which is kept under seal until the prosecutor is ready to move forward with the case. Once the indictment is unsealed, the defendants named in the indictment will be arrested.

By retaining a Los Angeles/Southern California healthcare fraud attorney before indictment and arrest, this process can be much less intimidating. A great defense to healthcare fraud requires early intervention at the earliest possible stage. If an indictment has not been issued, a thorough investigation and compliance plan may remedy the issue before indictment.

How are Healthcare Fraud Charges Defended?

When a healthcare professional is indicted for healthcare fraud, the government has probably completed a thorough investigation.

A great defense to healthcare fraud requires early intervention at the earliest possible stage. If an indictment has not been issued, a thorough investigation and compliance plan may remedy the issue before indictment.

If an indictment has been issued, counsel must work quickly to analyze insurance claims, patient records, witness statements, and the government investigation.

The ideal defense attorneys will handle your healthcare fraud charges by first reviewing the medicine in order to make the case that the claim was properly billed or, at the very least, not billed with the intent to defraud. Such a defense requires expert testimony from a certified biller and a health professional of the same profession, to testify that the medical decision-making was not fraudulent.

If the argument cannot be made that the medical decision-making is defensible, we review the Medicare bills to argue that the amount of the fraud (called the loss amount) was so low that it is not evidence of a scheme.

If a trial is necessary, it is imperative that expert testimony is presented to assert that the claims were not fraudulent. It also is vital that certain motions and objections are made that would restrict the government’s evidence in order to improve your chances of a successful outcome.

How Does the Healthcare Fraud Criminal Case Proceed?

The initiation of healthcare fraud charges begins with the unsealing of a federal indictment. An indictment is issued by a grand jury and is then kept sealed until the prosecutor is prepared to arrest and process all defendants.

Once the indictment is unsealed and you are formally charged, you and any co-defendants will either be arrested by federal agents, or your attorney(s) will be notified of the need to “walk in” for arraignment.

This is one reason why it’s imperative to contact a Los Angeles/Southern California healthcare fraud defense attorney who is familiar with the prosecutor. Your counsel may be able to prevent arrest on the indictment and request that you “walk in” for initial appearance without the embarrassment that an arrest from your home or work will cause.

This begins a series of stages in the adjudication process leading to the resolution of the case in one of three ways: trial, negotiation and acceptance of a plea offer, or a dismissal. Here are the general steps during the progression of a healthcare fraud case:

1. Pre-Indictment Investigation

Hopefully, if you are reading this, you are doing so because you suspect that charges may be brought against you. If so, you have an opportunity to have an aggressive advocate right from the beginning, because you are in what is known as the pre-indictment investigation stage.

At this point, the government’s agents are doing everything they can to get evidence they believe will suffice to convince a grand jury to charge you with fraud and related offenses. Many people suspected of fraud offenses miss the important opportunity available during this stage, to obtain the services of a lawyer who can conduct his/her own investigation, engage in negotiations with the government, and even convince the government not to pursue charges.

2. Indictment

If you are being charged in federal court with healthcare fraud — whether involving Medicare, Medicaid, TriCare, or other — you will likely already have heard the term “indictment.” The indictment is the document that the prosecuting agency — generally, the local U.S. Attorney’s Office— uses to tell you and the U.S. District Court the criminal charges that are being brought against you.

The indictment is created secretly by a grand jury, then kept sealed until the U.S. Attorney decides to arrest and process everyone who is charged in the indictment. In general, the indictment will name doctors, office staff, pharmacists, DME providers and others involved in the care of patients and the provision of medication, goods, and other services.

If you are unable to avail yourself of the assistance of an attorney before the indictment is unsealed, or if the government nevertheless decides to proceed with charges, and the grand jury issues an indictment, the government will unseal the indictment and you will be brought to court. From this point, the case will proceed with an often-dizzying speed.

That’s why it’s crucial to have an attorney who is not only an effective advocate for you, but who also understands the importance of helping you understand and be prepared for the proceedings, right from the start.

Even at the indictment stage, the importance of a reputable, established attorney is paramount. That’s because the unsealing of the indictment is the last step before a defendant is either arrested by agents of the federal law enforcement agency that conducted the investigation (often the DOJ’s multi-departmental Health Care Fraud Strike Force, or the HHS’s Medicare Fraud Strike Force), or is told by an attorney that the suspect has already retained, and who has already contacted the investigating agency, that he or she needs to “walk in” to be arraigned in court.

You will need a seasoned Los Angeles/Southern Califonria health care fraud defense attorney — one who whose aggressive, thoughtful advocacy has already earned the respect of the investigating agencies and prosecutors, one who can make the process easier — right from the beginning.

3. Pre-Trial Services Interview, Arraignment, and Bond

Immediately after you are arraigned, an office of the court known as Pre-Trial Services will interview you to decide whether, and under what conditions, you can be released on bond.

Arraignment simply means being you are informed of the charges, by a federal magistrate, to determine how you will plead. The judge will then determine whether you can be released on bond.

Only an experienced Los Angeles/Southern California healthcare criminal defense attorney will understand the importance of this decision, as outcomes for defendants released on bond — who have the breathing room to review their options with their attorneys — are consistently better than for those forced to make life-altering decisions while in pre-trial custody. Likewise, only a reputable healthcare fraud attorney accompanying you through the pre-trial services interview will be able to give you the best chance of release on the least-restrictive bond conditions. 

4. Discovery Phase

After bond is decided, the case enters what is known as the discovery phase, during which you and your attorney begin to be provided with some of the evidence the government intends to use to prove that you committed the charges in the indictment.

However, the Federal Rules of Criminal Procedure, which lay out many of the procedures and obligations of each party in a criminal case, do not require the government to provide all of the information in its possession — at least not at this stage.

Nor, obviously, does the government know everything about your case, which is why, during this time, your counsel also conducts an investigation. Just as the government’s disclosures may continue throughout the proceeding, so will our search for any material we can use to mount the best possible defense. (We believe that the best defense is a good offense, and we hope that, even if you choose another attorney, you will be wary of anyone who does not engage in his/her own investigation.)

5. Motions Phase

While the discovery is ongoing, and as your attorneys review the information they are provided, they will file any of a number of pre-trial motions. A variety of motions exist for a variety of purposes; some ask the court to require the government to provide additional discovery, to prevent it from using certain evidence, or to dismiss one or all charges.

6. Plea Negotiations

Good pretrial motions practice, as well as good discovery practice, have an important purpose apart from their direct ones: each can be used as a powerful tool in your attorney’s plea negotiations.

Even assuming you didn’t commit the alleged offense, a good healthcare fraud attorney will continuously engage the government in negotiations to get you a “deal.” Such negotiations can help your attorney learn more about the government’s case against you and the tactics it plans to use at trial. They can even help convince the government to amend the indictment and allow you to plead guilty to some lesser charge.

7. Pre-Trial Hearing/Plea Cutoff Hearing

Eventually, your case will be set for a pre-trial/plea cutoff hearing. This is the last pre-trial hearing before the jury trial begins, and it is the date at which the judge finds out whether you wish to plead guilty pursuant to a plea agreement between you and the government (a “Rule 11”), or whether you wish to “put the Government to its burden” by demanding your constitutional right to a jury trial.

If you indicate that you do intend to go to trial, your lawyer, the judge and the prosecutor will use this hearing to discuss how and when the trial will take place.

8. Trial Date

Once your trial date comes, you can expect your trial to last anywhere from a week to several months. Healthcare fraud trials can have such varying lengths because of the variation in complexity and number of co-defendants in different cases.

9. Sentencing

If a jury finds you guilty beyond a reasonable doubt on at least one charge, or if you plead guilty, either by way of a plea agreement, or an “open plea” directly to the court, you will be given a date for a sentencing hearing.

This hearing allows the judge to review information about you and your case, which has been collected by Pre-Trial Services and presented in a Pre-Sentence Investigation Report (PSR). This report typically includes information the pre-trial officer gets during an interview with you, at which your attorney should be present, and for which he or she should have prepared you.

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What Are the Consequences of a Healthcare Fraud Conviction?

The consequences of a healthcare fraud felony conviction can last longer than just a term of incarceration, so it is important to weigh all your options before accepting any plea deal or deciding to go to trial. A plea to accept a felony charge for healthcare fraud or Medicare fraud should not be based solely on the potential jail time

In addition to a possible prison term (many healthcare fraud crimes carry a potential maximum 10- or 20-year prison sentence), a conviction may result in:

    • Mandatory felony conviction
    • Prohibition on billing any federal entity for between five years and life
    • Loss of professional license (medical license, pharmacy license, nursing license)
    • Jail time (many healthcare fraud crimes carry a potential maximum 10- or 20-year prison sentence)
    • Forfeiture of all assets related to the alleged offense
    • Fines of up to $250,000 per offense
    • Restitution
    • Job loss
    • Loss of board certification status

Los Angeles healthcare fraud defense attorneys understand the magnitude of these ramifications on a healthcare professional’s career, and they will work to minimize the fallout.

How are Healthcare Fraud Sentences Determined?

Sentencing for violations of federal law is informed by Federal Sentencing Guidelines, which provide a sentencing range in months of imprisonment based on a person’s criminal history and the offense itself. Various mitigating or aggravating factors can decrease or increase the sentencing range.

While the court is not required to abide by the sentencing range outlined by the guidelines, it provides a framework that is heavily relied on in courtrooms throughout the country.

Our Los Angeles/Southern California healthcare fraud defense attorneys are skilled at calculating these guidelines. Understanding an accurate score of individual factors — such as the fraud loss amount or the drug quantity in cases involving convictions under the CSA — is important when advocating for the overall lowest possible sentence.

As a result of the Affordable Care Act, the number of claims billed to a healthcare program is considered prima facie evidence of the loss amount. In the event of conviction and in order to achieve a lower sentence, it is imperative that defense counsel challenge the notion that the number of claims billed is the amount of the loss to the government.

Every healthcare provider knows that Medicare, Medicaid, and private insurance companies do not actually pay the amount billed. Usually it is some lesser amount.

Under no circumstances should someone facing healthcare fraud charges accept the government’s recitation of the loss amount. The government’s loss number is generally inflated and created using poor methodology.

But a well-skilled healthcare fraud defense counsel will know other strategies useful for determining a lower loss amount, such as claim sampling and extrapolation.

As an example, let’s say a Burbank pharmacist fraudulently billed Medicare for reimbursement of prescriptions for non-existent patients. If the government claims the loss to the Medicare program was at least $1 million but less than $1.5 million, the potential prison sentence could be 30 to 37 months.

But, if by aggressively investigating the case data, a team of Los Angeles/Southern California Medicare fraud lawyers can show the loss to the Medicare program was actually less than $550,000, the potential prison sentence can be substantially lowered to 18 to 24 months.

Once that is accomplished, your healthcare defense attorneys can work toward getting the final sentence recommendation to a level that can be non-prison.

This scenario is precisely why you need a dedicated Los Angeles/Southern California healthcare fraud defense attorney to defend your Medicare or Medicaid fraud case.

Why Should I Call the Los Angeles Healthcare Fraud Defense Lawyers at Chapman Law Group If I Am Charged with Fraud?

Facing something as career-threatening as healthcare fraud means your whole world is hanging in the balance.

You need to have a Los Angeles health care fraud defense lawyer you can fully trust. You need the confidence to know that he/she is fighting for you and looking out for your best interests.

You need to be certain that your lawyer can take a case to trial and is not looking to just plead you guilty. Your lawyer must be reachable when you have questions.

At Chapman Law Group, we aggressively protect clients’ rights every step of the way. Our lawyers strive to always keep clients informed, explain the process, and answer any and all questions.

Our Los Angeles health care fraud defense attorneys have been battling these federal Medicare fraud strike forces for several years, so our healthcare clients get the kind of Medicare fraud defense no one else can offer.

We have keen insight into the feds’ and the strike force’s tactics. We can detect their weaknesses. And we know how to get results for our clients facing healthcare fraud indictments. Our Los Angeles healthcare fraud defense attorneys have a reputation in winning many cases by dismissal or not-guilty verdicts at trial.

We also know that fighting a case through trial places a heavy burden — emotionally and financially — on a family. And one of the critical differences between the Chapman Law Group and other criminal law firms is our focus on preventing an arrest and charges from being filed.

We actively investigate allegations and start building a defense for our clients before the case ever goes to court.

Many times, we can convince the government not to file charges, contending that our client committed no crime. In other instances, we are able to resolve a case through a diversion agreement, which results in a case dismissal. And in some situations, we can settle a case through a civil agreement and payment of a fine.

Even in situations where criminal charges are filed, we are often able to get a result that would substantially reduce the potential jail time and other penalties.

And, moving forward, we can help you develop a stronger, more effective compliance program for your practice, so as to avoid accusations of healthcare fraud and be prepared if the government decides to conduct an audit.

For Healthcare Fraud Criminal Representation in Los Angeles, the Attorneys at Chapman Law Group Stand Apart

When you have government investigators staring you down and accusing you of healthcare fraud, Chapman Law Group is the law firm for you.

For 35 years, our healthcare lawyers have aggressively defended licensed healthcare professionals on criminal matters — from the internal investigation right up through trial.

We have honed our expertise in defending providers against healthcare fraud charges by obtaining pretrial dismissals, not-guilty verdicts, and beneficial plea agreements in federal courts across the U.S. 

Many of our attorneys have earned advanced degrees in healthcare law from Loyola University Chicago School of Law — the top school in the U.S. for health care law.

Our dedicated Los Angeles healthcare fraud defense lawyers are led by a former federal prosecutor and staffed with attorneys who exclusively defend healthcare fraud cases — many of whom have advanced degrees in healthcare law.

We are solely dedicated to representing licensed healthcare providers — including physicians, pain management specialists, pharmacists, and psychologists — in criminal law matters such as healthcare fraud.

Besides having a proven track record of winning healthcare fraud cases by dismissal or not-guilty verdicts at trial, our knowledge, training, and experience ensure that we are able to do so more quickly — and with less expense — than other criminal defense lawyers.

Very few law firms in the U.S., if any, can make these claims and back them up with our results.

Our clients include practitioners in cities, counties, and communities all across Los Angeles and Southern California — Pasadena, Long Beach, Santa Monica, San Fernando Valley, San Bernardino, Anaheim, Irvine, Huntington Beach, Newport Beach, as well as Los Angeles County, Orange County, Ventura County, San Bernardino County, and Riverside County.

Besides Southern California, we at Chapman Law Group have healthcare-based criminal law defense offices in Detroit, Michigan; and Miami and Sarasota, Florida.

Contact us today to learn more about what an experienced, reputable Los Angeles health care fraud defense attorney can do for you, and how we are ready to help you with the best healthcare fraud defense. 

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