Our team of attorneys is dedicated to defending providers and suppliers suspected of Medicare fraud. Our team includes a former Deputy Attorney General for the Medicaid Fraud Control Unit (MFCU) who prosecuted health care fraud cases. They have significant experience in health care fraud investigations, audits, and civil and criminal Medicare fraud actions. We have built our team of Medicare fraud defense lawyers to represent individuals accused of fraud nationwide, through offices in Detroit and Troy, Michigan and Miami and Sarasota, Florida. Our clients include physicians, chiropractors, pharmacists, home health agencies, urgent care centers and behavioral health facilities.
What is Medicare Fraud?
Medicare fraud encompasses the false claims act, anti-kickback Florida, Anti-kickback Michigan, Stark and health care fraud statutes, and is when an individual knowingly submits a false statement or makes misrepresentations of fact, to obtain payment from a Federal health care program (Medicare, Medicaid or TRICARE) for which no entitlement would otherwise exist. Individuals who knowingly solicit, pay and/or accept remuneration to induce or reward patient referrals for services or supplies reimbursed by a Federal health care program, may also be guilty of Medicare fraud, along with those making prohibited referrals for certain designated health services.
Examples of Medicare Fraud
Submitting false claims to CMS for payment
Billing for services or supplies not provided
Ghost patients: submitting claims for services or supplies for a patient who does not exist or who the provider has no physician-patient relationship
Billing for services of such low quality that they are virtually worthless
Billing for durable medical equipment not legitimately prescribed by doctors
Unbundling: billing for tests or treatment separately where there is an ICD-10 procedure code that covers/bundles the services
Up-Coding: billing a higher code (CPT, ICD-10, E&M, HCPCS) than the service actually performed
Lack of medical necessity and overutilization: performing additional treatments or tests which are not clinically necessary
Utilization of excluded providers: submitting a claim on behalf of a provider that is ineligible to participate in Medicare and Medicaid
Non-Medicare participating providers billing patient more than 15% above the Medicare fee schedule, when a patient seeks reimbursement from Medicare
Making false statements on applications or contracts to participate in Medicare or Medicaid program
Providing false or misleading information expected to influence a decision to discharge a patient
Violating Medicare assignment provisions or the physician agreement
The Requirement for Medicare Fraud Conviction
Criminal Medicare fraud convictions require proof beyond a reasonable doubt that an individual knowingly and/or willfully submitted a false claim or engaged in kickbacks or health care fraud. However, proof of actual knowledge or specific intent is not required for a conviction. A person can be convicted if they are found to have acted with deliberate ignorance or reckless disregard of the truth or falsity of the claim. In some Medicare fraud cases, the ultimate issue is simply whether the individual acted knowingly and/or willfully. In other cases, the issues are much more complex. For example, Medicare fraud allegations involving worthless services, medical necessity or overutilization present an additional question regarding the standard of care. The current government trend is to criminally charge physicians who allegedly prescribe/perform health care services that are not medically necessary. Our Medicare fraud defense lawyers are uniquely suited to defend these claims. Our knowledge of conditions of payment, conditions of participation, and over 31 years defending physicians accused of malpractice give us the knowledge to understand and apply the standard of care, DRG’s, CPT’s, clinical practice guidelines and conditions of payment in the defense of our clients.
Medicare Fraud Related Charges
In addition to defense, our attorneys are experienced in defending charges related to fraud, including:
Attempt and Conspiracy to Commit: Any person who attempts or conspires to commit any offense under the health care fraud chapter is subject to the same penalties for the prescribed offense
Forfeiture: Property alleged to be constituting or derived from any proceeds of unlawful activity, directly or indirectly, or property used or intended to be used in any manner or part to commit or facilitate the alleged Medicare fraud, may be subject to forfeiture.
Money Laundering: Using proceeds from unlawful activity to promote or conceal that activity, or engage in transactions greater than $10,000 derived from the alleged claim.
Theft of Government Services: Can include billing for services performed by a provider, vendor or entity excluded from the Medicare program. This includes indirect billings made by an employer or practice group for services performed on a Medicare beneficiary by an employee who is excluded from the Medicare program.
Wire Fraud: The use of electronic communication or telephone in interstate communications made in furtherance of the alleged Medicare fraud.
Possible Medicare Fraud Sanctions
Civil Monetary Penalties:
False Claims Act – up to $21,563 per claim and a fine three time the number of damages sustained by the government as a result. Fine up to $250,000 if knowingly
Anti-Kickback Statute – up to $50,000 per violation and a fine three times the amount of the kickback
Health Care Fraud – up to $250,000
Exclusion Statute – up to $10,000 per item claimed while excluded and a fine three times the amount claimed
Healthcare Fraud: up to 10 years. Up to 20 years if bodily injury
Conspiracy to Commit Healthcare Fraud and Fraud: up to 20 years
False Claims Act Convictions – up to 5 years per occurrence. Up to Life if convicted of multiple counts
Money Laundering: up to 10 years
Conspiracy to Commit Money Laundering: up to 20 years
Wire Fraud: up to 20 years
Other Sanctions and Collateral Consequences:
Loss of Licensure
Loss of DEA Registration
Exclusion from Medicare and Medicaid
Suspension of Payment on Outstanding Invoices
Loss of Staff Privileges
Loss of Employment
Experienced Medicare Fraud Defense Attorneys
Early intervention of a skilled lawyer knowledgeable, not only in criminal healthcare defense, but health care law as well is key. Medicare fraud prosecutions are highly specific prosecutions lead by the U.S. Attorney’s Health Care Fraud Division. Thus, the defense of such allegations requires a team of highly specialized Medicare fraud defense attorneys capable of analyzing a voluminous amount of health data with knowledge of billing practices, compliance issues and medical necessity.
Our Current Medicare Fraud Cases
Several home health agencies: Alleged to have committed Medicare Fraud for improper referrals, performing services outside the plan of care, not having proper authorizations, not having proper re-certifications, etc.
Behavioral services agencies: Alleged to have committed Medicare fraud for failure to use the proper CPT code resulting in allegations of fraudulent billing.
Compound pharmacies: We currently defend several individuals in multiple areas regarding compounding pharmacies. Generally, the allegation is that the pharmacy is “mining” patients through the use of a call center boiler room and the patients have no legitimate medical need for the compound, or the allegation is the compound serves no legitimate medical purpose and is no better than an over the counter medication or less expensive script.
Several physicians: Charged with receiving remuneration of referring patients and for approving plans of care that were not medically necessary.
Medical directors: Alleged to have committed Medicare fraud for receiving a salary or other payment, as well as referring patients to the program they currently work as the medical director.
Two physicians were charged with unlawfully prescribing suboxone while working at Redirections Treatment Advocates (RTA) in Wierton, WV. Based on our specific experience in defending addiction medicine providers and Suboxone, Ron Chapman II was asked to join the trial team on this case and other companion cases.
Our client owned a busy urgent care in Southeast Michigan. The Michigan Attorney general sent undercover patients into our client’s clinic and determined that our client was billing for services that were not rendered.