Health care providers and medical businesses in Charlotte, NC are being targeted in federal audits and investigations. If your billing or prescription practices are under the microscope, you need to speak with a federal health care fraud defense lawyer as soon as possible.
If your medical practice or health care business is being audited, or if you are under investigation by federal authorities, you are at risk for severe penalties. Under federal laws such as the False Claims Act and Anti-Kickback Statue, even unintentional violation can result in significant financial penalties and loss of Medicare, Medicaid, Tricare, VA, and DOL benefit program eligibility. If there is evidence to suggest that you intentionally over-billed the federal government (or if there is evidence that you had “constructive knowledge” of regulatory or statutory violation), then you could be at risk for criminal prosecution and spending years – if not decades – behind bars.
If this sounds extreme, it is. If it sounds out of the realm of possibility, it isn’t. Federal authorities are aggressively targeting health care providers in Charlotte and other major cities around the country, and the U.S. Department of Justice (DOJ) has recently conducted several large-scale take-downs resulting in a multitude of criminal charges against physicians, business owners, and other individuals.
Are You Being Targeted in a Federal Health Care Fraud Audit or Investigation in Charlotte? Here’s What You Need to Know:
1. CMS’s “Fee-for-Service” Audit Contractors Get Paid to Uncover Billing Violations and Demand Recoupments.
Audits targeting health care providers’ Medicare and Medicaid billings can be invasive, disrupting, time-consuming, and costly. While audit contractors working with the Centers for Medicare and Medicaid Services (CMS) are supposed to identify both overpayments and underpayments, their compensation structure means that they are financially-incentivized to seek recoupments over informing providers that they are entitled to additional payments from Medicare and Medicaid. As a result, without aggressive intervention, audits almost always result in financial liability for program-participating health care providers.
However, Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and Zone Program Integrity Contractors (ZPICs) routinely make mistakes during audits. This includes relying on outdated billing guidelines, using improper auditing methodologies, and making faulty assumptions about providers’ practices. We have extensive experience defending clients in MAC, RAC, and ZPIC audits; and, if you get us involved promptly, we can deal with the auditors on your behalf to make sure you are not unjustly penalized for compliant program billings.
2. Multiple Federal Agencies and Task Forces Conduct Health Care Fraud Investigations.
Unlike audits, health care fraud investigations are conducted directly by federal agencies and task forces. While some investigations will involve a single agency or task force, it is not unusual for multiple federal authorities to cooperate in pursuing an investigation. Our attorneys, several of whom are former health care fraud prosecutors, have extensive experience on both sides of federal health care fraud investigations involving:
- Centers for Medicare and Medicaid Services (CMS)
- Drug Enforcement Administration (DEA)
- Federal Bureau of Investigation (FBI)
- Internal Revenue Service (IRS)
- Medicare Fraud Strike Force
- Opioid Fraud and Abuse Detection Unit
- Prescription Interdiction and Litigation (PIL) Task Force
- U.S. Attorney’s Office
- U.S. Department of Justice (DOJ)
- U.S. Department of Defense (DOD)
- U.S. Department of Veterans Affairs (VA)
- U.S. Department of Health and Human Services’ Office of Inspector General (OIG)
3. The Civil and Criminal Penalties for Federal Health Care Fraud are Severe.
Regardless of whether you are being targeted for unintentional billing violations (which likely mean that your case is civil in nature) or you are being accused of intentionally overbilling the government or diverting opioid drugs (which are criminal offenses), the penalties you are facing are severe. Civil penalties under the False Claims Act, Anti-Kickback Statute, and Stark Law include:
- Recoupments
- Treble (triple) damages
- Civil monetary penalties (CMP)
- Denial of pending claims
- Prepayment review of future claims
- Program exclusion
If you are under investigation for criminal health care fraud in Charlotte, potential penalties include:
- Criminal fines (which could easily add up to hundreds of thousands or millions of dollars)
- Program exclusion
- Federal imprisonment
4. Health Care Fraud Allegations Can Also Lead to Licensing Action and Loss of DEA Registration.
In addition to statutory civil and criminal penalties, federal health care fraud allegations can have a number of other potential consequences as well. For example, for DEA registrants, an investigation targeting prescription drug-related fraud offenses could lead to loss of DEA registration. Federal investigations can also trigger licensing action by the North Carolina Medical Board and other state-level licensing authorities; and, since the standards for federal culpability and ethics violations differ, it is possible to face licensing action even if an investigation does not lead to federal charges.
5. Auditors and Federal Authorities are Looking for Any and All Forms of Intentional and Unintentional Billing and Coding Violations.
Most health care fraud investigations target billing and coding errors. These errors can take many different forms, and they can involve mistakes made by internal personnel as well as third-party billing administrators. Delegating your program billing responsibilities to a third party is not an excuse for non-compliance, and each of the following types of errors can potentially lead to substantial liability:
- Overbilling Medicare, Medicaid, Tricare, the VA, or the DOL (including unbundling, upcoding, and other common coding mistakes)
- Double-billing the federal government and/or a private insurer
- Billing for services, medications, supplies, or durable medical equipment (DME) not actually provided
- Billing for services that do not meet the relevant requirements for “medical necessity”
- Falsifying patient records, test results, physician certifications, or other documentation
6. Agreements and Financial Relationships with Other Health Care Providers Can Get You into Trouble.
While it is possible to structure agreements and financial relationships with other health care providers to comply with the Anti-Kickback Statute and Stark Law, doing so requires a thorough understanding of these laws’ prohibitions and the specific exceptions and “safe harbors” that are available. All types of providers and businesses can face liability (civil or criminal) under the Anti-Kickback Statute, while the Stark Law applies specifically to Medicare and Medicaid-participating physicians.
7. Telemedicine, Opioids, CBD, CGX, and Alzheimer’s Testing are All “Hot Button” Issues in Federal Health Care Law Enforcement.
From time to time, the DOJ and other federal authorities identify specific “hot button” issues that become top federal law enforcement priorities. Currently, the DOJ and other agencies are paying particular attention to Medicare, Medicaid, Tricare, VA, and DOL billings for:
- Telemedicine
- Opioid prescriptions
- CBD medications
- Genetic cancer screening (CGX)
- Alzheimer’s testing
8. If You Let the Audit or Investigation “Run Its Course,” It Probably Isn’t Going to End Well.
Many practitioners and business owners particularly those who believe they have done nothing wrong assume that they can simply let an audit or investigation “run its course” and they will come out fine on the other end. However, this is a mistake that far too often proves to be extraordinarily costly. By the time you discover that your business or practice is the subject of a federal health care fraud inquiry, there is a good chance that auditors or federal agents already have reason to believe that you have improperly billed the federal government. As a result, you need to take defensive action, and you need to do so as soon as possible.
9. Your Choice of Legal Representation Matters.
If your Charlotte health care business or medical practice is facing scrutiny from CMS audit contractors or federal agents with the DEA, DOJ, OIG, or any other agency, your choice of legal representation matters. You need a defense team that can effectively intervene in the audit or investigation, and that can execute a sound defense strategy focused on protecting you to the greatest extent possible. If you choose lawyers who aren’t adequately equipped to defend you, you could suffer the consequences for decades to come.
10. Our Federal Health Care Lawyers have Centuries of Experience and a Proven Track Record of Success.
At The Criminal Defense Firm, we have a proven track record of success in federal health care fraud audits and investigations. Our senior lawyers and expert federal health care consultants bring centuries of combined experience to advising and representing providers and businesses in audits and investigations. When you choose The Criminal Defense Firm for your federal health care fraud matter in Charlotte, NC, we will:
- Promptly intervene in the audit or investigation in order to slow down the process and gather the information we need to execute a strategic defense.
- Carefully advise you and your key personnel every step of the way so that you know what you need to do and what mistakes you need to avoid.
- Work efficiently to resolve the audit or investigation without charges so that you are not at risk for facing civil or criminal penalties at trial.
- Make ourselves available to you 24/7 by phone, text, and email, and respond as soon as possible if we are not available to speak with you immediately.
- Diligently and aggressively pursue a positive outcome that protects your finances, keeps you out of prison, and allows you to maintain your health care business or medical practice.
Schedule a Free Initial Consultation at The Criminal Defense Firm
If you need to speak with a lawyer about a federal health care fraud audit or investigation in Charlotte, we encourage you to contact us immediately. To speak with a member of our defense team in confidence, call 214-251-4238 or request a free case assessment online now.