HEALTH CARE FRAUD
With ever tightening health care budgets come ever more intrusive regulatory investigations; the pursuit of health care fraud and abuse has also heightened, since claims of abuse are more widespread than ever, but the innocent are too often swept up by that tide of eager prosecution. While some health care professionals may be cutting corners, most are entirely honest and diligent. Remember, whether something is viewed as a “mistake” versus a “crime” is too often based on subjective analysis by over-eager investigators or cost-cutting bean counters.
Almost any practitioner who engages in treatment and billing activities could be challenged by regulators, no matter how hard the practitioner works to be honest. If an eager investigator puts the “right” spin on the conduct he or she observed, charges and accusations can always follow. Too often it becomes a question of who is looking and how aggressive they are, not whether someone is actually trying to cheat the system or violate the law.
The United States Department of Justice has expanded its Medicare Fraud Task Forces across the country, and far more marginal blunders and billing errors are now called “fraud” than ever before.
COMMON HEALTH CARE FRAUD CHARGES
- Prescription and Medical Fraud: Overprescribing, Overutilization, Overbilling
- Medicare Fraud (Federal)
- Medicaid Fraud (State)
- Referral Fees for Bringing Patients — Kickbacks (Under Federal Law)
Federal, state and private-payer insurance companies have similarly grown increasingly more aggressive in pursuing what is found to be the most minor transgressions — things that always used to be merely civil (financial) issues have now been reclassified as criminal. Thus, far more health care providers who are seen to have come “close to the line” in treatment decisions and billings are pursued aggressively.
As health care payers push harder to uncover improprieties, health care fraud attorneys also need to become more aggressive than most are in defense of their clients, especially those whose conduct was born out of little more than mistake. Federal Criminal Defense Lawyer James W. Burdick brings just the right blend of aggressive skills, experience and practical expertise to give health care professionals the greatest likelihood of success in defending such charges.
OVERPRESCRIBING; OVERUTILIZATION; OVER-BILLING
In an effort to combat health care fraud, state and federal prosecutors have increased criminal prosecutions of doctors involving the overprescribing of drugs. While most cases involve the prescription of opiates and powerful pain medication like Oxycontin, investigators have also pursued cases involving what they say is excessive infusion drug therapies. Allegations typically claim the drugs prescribed exceeded a patient’s need, resulting in a violation under federal statutes like 21 U.S.C. 841. These charges put the practitioner in the same “class” as heroin or cocaine dealers.
Overprescribing of opioids and other controlled substances is a big problem, but sometimes it’s not done for bad reasons — just poor choices. These physicians are lumped into the same category by the government as people intentionally overprescribing for financial gain. Jim Burdick counsels and defends doctors and pharmacists accused in drug overutilization cases involving Hydrocodone, Oxycodone, Oxycontin and Anabolic Steroids, as well as Ativan, Xanax and other tranquilizers.
“Apart from being an extraordinary lawyer, you are a great human being. Thanks for doing all that you have done for me. You understood my situation, fought and still continue to fight for me. Nobody could have provided such immense help that you did. You earned great respect in my heart, my life, and my prayers.”
A physical therapist who was facing 10 years in prison
MEDICARE FRAUD: FALSE BILLINGS OR OVERBILLING; UP-CODING; OVERUTILIZATION
In recent years, state and federal investigators have increased efforts to curb Medicare and Medicaid fraud. As a result, overzealous prosecutors can initiate an investigation against doctors, clinics, hospitals and medical supply companies when patterns emerge involving billing and referrals. Sometimes, in their zeal to catch those who are breaking the law, innocent health providers are swept up into someone else’s misdeeds. In the process, investigators may audit a suspect’s finances, office records or tax returns looking for anything that would suggest unreported income and a pattern of fraud.
We understand how health care fraud investigations are conducted. If brought in early enough, we can meet with investigators, answer their questions and diffuse or deflect further investigation of our client. We also counsel and advise doctors, hospitals, pharmacists and medical suppliers in how to avoid obstruction of justice charges without incriminating themselves.
In most overbilling health care fraud cases, the Current Procedural Terminology (CPT) codes or the Health Care Common Procedure Coding System (HCPCS) are involved. Even for a seasoned health care or insurance professional, the CPT and HCPCS codes can be difficult and even perilous to try to understand and navigate. As a result, a health care provider may consistently make the same kind of mistake in using CPT or HCPCS codes when billing Medicare or Medicaid. Unfortunately, to an overzealous investigator, what is in reality an honest mistake may instead be converted into a claimed pattern of fraud.
In defending our clients, we work closely with claims adjudication professionals, accountants, physicians and medical billing experts. As your attorney, Jim Burdick points to ambiguities within the CPT and HCPCS codes, explaining your actions within the framework of the treatment provided and the confusing nature of the CPT and HCPCS systems.
“REFERRAL FEES” (KICKBACKS) FOR BRINGING PATIENTS
Typically, investigators grow suspicious when they see what they believe is a pattern of referrals among a specific group of doctors or health care providers. If independent clinics are involved where doctors have an ownership interest in the practice, investigators will review referral records in order to identify what they believe is a pattern of fraud. A kickback fraud investigation can also involve the use of “runners,” people who are paid on the basis of patients brought to a practice, as well as unnecessary medical testing.
In defending our clients, we work with medical experts, accountants and private investigators if necessary in exposing the groundless assumptions of prosecutors. Here, it’s often a matter of demonstrating the existence of valid medical reasons for a referral and explaining why what investigators take to be a pattern of fraud is, in reality, a working relationship among medical professionals.
Whether you’ve been indicted or are under investigation for health care fraud, contact Health Care Fraud Attorney Jim Burdick today.
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