If you’re a Tennessee-based physician, pain management specialist, pharmacist, nurse, or chiropractor, and you’ve been accused of healthcare fraud, you need to act immediately, and contact one of our Nashville healthcare fraud defense lawyers. Why? Because Nashville and Tennessee have one of the highest rates of federal healthcare fraud indictments in the country, so much so that in 2010 the Department of Justice created a special “strike force” to prosecute healthcare fraud in the Nashville and greater Appalachian area.
Although Nashville is considered the healthcare capitol of the world and a hotbed for healthcare fraud, healthcare providers from all corners of Tennessee, from Memphis to Knoxville, and from Murfreesboro to Franklin, are susceptible.
Tennessee is one of the most aggressive states in the nation when it comes to policing possible Medicaid fraud among beneficiaries. The state posts the names and photos of people arrested for alleged fraud on a government website and social media. Some even wind up on a so-called “most wanted” list, as if they were dangerous and on the run.
The list is maintained by Tennessee’s Office of Inspector General. The office was launched in 2005 when most of the cases involved drug diversion: people were accused of using TennCare benefits to acquire massive quantities of narcotics to sell on the street. But as federal rules have slowed the illegal prescription drug market, arrests related to Medicaid are instead sweeping up people accused of moving out of state, often within the same community, without canceling their benefits.
If you find yourself accused of healthcare fraud, it’s vitally important to understand that any time spent delaying, puts you in greater risk, and any action you take could affect you and your family for years to come. For this reason, it is important that you know what healthcare fraud is all about, how investigations take place, and the paths cases can go.
Healthcare fraud is a type of white-collar crime that involves the filing of fraudulent healthcare claims. 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. When a claim is submitted for reimbursement for services that were either not medically necessary, not conducted, overbilled, or not allowable, the person and entity that caused the bill to be submitted can be prosecuted for fraud.
Healthcare fraud can be committed by anyone who bills or causes a bill to be submitted to a healthcare entity. This definition is very broad, and it does not require that someone actually submit a bill to a health benefits program. In order to be convicted of healthcare fraud, the government must prove, beyond a reasonable doubt, that the defendant:
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.
Individuals depicted or heard in the foregoing media appearance or images may no longer be current attorneys, employees, members or affiliates with Chapman & Associates, PC or The Chapman Law Group (the “Firm”), including Ronald W. Chapman, II who is no longer affiliated with the Firm. For a current listing of the attorneys and services available with the Chapman Law Group, please see
https://chapmanlawgroup.com/team.
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:
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, and 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.
Healthcare fraud is a federal issue, and as such is investigated by federal agencies that are not strictly confined to Nashville or Tennessee as a whole. These agencies include:
Typically, healthcare fraud is initially investigated using data. The Centers for Medicare & Medicaid Services (CMS) and HHS review statistical data generated from Medicare and Medicaid bills to look for outliers.
If you believe your practice is an outlier, you should contact a healthcare fraud defense attorney to begin your defense immediately, as quick action and a compliance plan may prevent indictment.
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. The initial audit may require review of only a few files, often called a probe audit.
If fraud is suspected after the 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.
In addition, Tennessee has its own Anti-Kickback Statutes.
Typically, a healthcare fraud indictment, which is the document that charges healthcare fraud, contains a charge of healthcare fraud conspiracy along with several individual executions of healthcare fraud. The indictment may also contain a money laundering charge in addition to a forfeiture charge.
The government charges healthcare fraud conspiracy because the federal conspiracy rules are extremely relaxed; they only require that the government prove an agreement to commit healthcare fraud and an act in furtherance of the scheme.
The government also makes attempts to seize a significant amount of assets of those charged with healthcare fraud, chiefly to prevent the defendant from using allegedly unlawful proceeds to defend healthcare fraud charges.
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, which is why you should call our Nashville healthcare fraud defense attorneys who specifically specialize in healthcare law.
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 Nashville Medicare fraud defense lawyer.
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 Nashville Medicare fraud attorneys 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.
Our Nashville healthcare fraud defense lawyers at Chapman Law Group have developed a professional rapport with many prosecutors. We are often able to arrange being notified before an arrest is made and, instead, have our clients voluntarily walk in for their initial appearance.
When a healthcare professional is indicted for healthcare fraud, the government has probably completed a thorough investigation. That said, the best defense to healthcare fraud charges is defensive legal 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’s investigation.
The ideal defense attorney 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 is also 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.
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 Nashville healthcare fraud defense lawyer who is familiar with the prosecutor. We 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:
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.
The potential consequences of a conviction of healthcare fraud, which our Tennessee healthcare lawyers regularly defend, are:
At Chapman Law Group, our Nashville healthcare fraud defense attorneys understand the magnitude of these ramifications on a healthcare professional’s career, and we work to minimize the fallout.
Individuals depicted or heard in the foregoing media appearance or images may no longer be current attorneys, employees, members or affiliates with Chapman & Associates, PC or The Chapman Law Group (the “Firm”), including Ronald W. Chapman, II who is no longer affiliated with the Firm. For a current listing of the attorneys and services available with the Chapman Law Group, please see
https://chapmanlawgroup.com/team.
Federal sentences are created using the Federal Sentencing Guidelines, which are a framework of rules used by judges to calculate the range of sentences for federal crimes. If someone is convicted of healthcare fraud, the sentence is almost exclusively determined by the fraud loss amount to the entity billed; generally, it is the value of claims billed.
Each crime is assigned an offense level. Levels are increased or decreased depending on specific details of the case. After all factors are considered, the final offense level corresponds to a penalty range. Possible prison sentences for healthcare fraud cases largely depend on the amount of economic loss to the federal reimbursement program. A basic way of looking at it is, an increased loss amount equals an increased prison sentence.
As a result of the Affordable Care Act, the amount 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 (your healthcare fraud lawyer) challenge the notion that the amount of claims billed is the amount of the loss to the government.
The rules and process for calculating loss amount favor the government. The sentencing guidelines define “loss” as “the greater of actual loss or intended loss,” and provide that the sentencing judge “need only make a reasonable estimate of the loss.” When a judge calculates the intended loss, absolute accuracy is not required, so long as the calculation is not “outside the realm of permissible computations.”
Courts have held losses caused by the acts of co-conspirators that were reasonably foreseeable to the defendant should also be included in the loss calculation. The sentencing court should, however, limit the defendant’s liability to those acts of coconspirators that were reasonably foreseeable and part of the criminal activity that the defendant “agreed to jointly undertake.”
In a healthcare fraud case, the amount fraudulently billed to the federal insurance program (Medicare or Medicaid) is “prima facie evidence of the amount of loss [the defendant] intended to cause,” but there can be additional evidence presented by the defense to demonstrate that this total “exaggerates” the defendant’s intent.
Loss includes all relevant conduct, including charged, uncharged, and acquitted conduct and is not limited to losses directly attributable to the defendant. For example, a defendant convicted of defrauding Medicare can be held responsible for the losses not only to the Medicare program, but also to private insurers and patients.
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. This where your well-skilled Tennessee healthcare fraud defense attorney will know other strategies useful for determining a lower loss amount, such as claim sampling and extrapolation.
As an example, let’s say a Nashville 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 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.
Throughout this article, we’ve broken down the complex process of federal healthcare fraud charges and the serious implications they carry for healthcare professionals in Nashville and the greater state of Tennessee. It’s clear that understanding these cases, from audits and strike force investigations, to potential indictments, is critical for anyone practicing medicine, pharmacy, or other licensed healthcare services nationwide. Whether you’re a physician, pharmacist, or administrator, being proactive and informed can make all the difference when dealing with potential allegations.
Our Nashville healthcare fraud defense lawyers at Chapman Law Group bring years of focused experience defending against federal Medicare and Medicaid fraud investigations. With $450 million saved, and 150+ acquitted, we work diligently to protect our clients through early intervention, thorough case preparation, and strong compliance strategies designed to prevent future issues. From counseling clients before charges are filed to advising on compliance programs that safeguard practices, our attorneys are committed to guiding you through every step of the process.
"*" indicates required fields
A Kentucky pain physician is acquitted of a nine-count indictment, including Unlawful Distribution and Health Care Fraud.
Our healthcare criminal lawyers’ in-depth knowledge of addiction medicine allowed our physician client to have the best possible chance at acquittal.
Healthcare fraud charges against a pain management physician were dropped after a 3 1/2-year legal battle, which stemmed from a widespread Appalachian Regional Prescription Opioid Strike Force sweep.
The United States Sentencing Commission has recently approved Amendment 821, Post Conviction Relief which started February 1st, 2024.
Our client, a home health business manager convicted of $2 million in healthcare fraud, was able to serve just three months of his 36-month sentence, arguing for “compassionate release” due to his age and health condition.
The government claimed that property taken from Dr. Joseph Oesterling was derived from illegal activity, but the appellate court struck the argument down.
