The healthcare fraud defense law firm The Criminal Defense Firm legally represents healthcare providers and individuals who have been accused of fraud in Detroit, Michigan. Prosecutors have honed in on Detroit for aggressive enforcement, leading to a higher rate of claims for healthcare fraud – many of them baseless – in Detroit. This has meant that more providers are getting accused of a serious offense that can carry significant fines and even the potential for jail time. Defending against these allegations, and creating a code of compliance that can avoid them being filed, in the first place, is something that the attorneys at The Criminal Defense Firm can do.
Our law firm is filled with talented, hardworking, knowledgeable, and dedicated lawyers who strive to represent medical providers against allegations of healthcare fraud. Many of our senior attorneys came to our firm with extensive experience prosecuting these very cases. Their experience on the enforcement side of the law gives them extremely valuable insight into how a healthcare fraud investigation will play out in Detroit, allowing them to work one step ahead of the prosecutor. Our clients benefit from this experience, and can rest assured that our team is working diligently to secure the best possible outcome.
What is Healthcare Fraud in Detroit?
Healthcare fraud is the act of making false statements in order to defraud funds from a healthcare program. This can happen in a variety of ways. Some of the most common are:
- Billing for medically unnecessary treatment
- Falsifying patient records
- Prescription drug fraud
- Using incorrect billing codes
- Accepting or giving kickbacks
- Taking illegal referrals
- Making false claims for healthcare funds by, for example, billing for medical care that was never provided
Some forms of fraudulent activity can fall under more than one of these types of healthcare fraud.
The lawyers at The Criminal Defense Firm defend healthcare providers against all of these serious allegations.
Billing for Unnecessary Treatment
A common allegation of healthcare fraud revolves around providing medically unnecessary treatment and care, in order to bill for it. The problem with this allegation is that it is often based on the judgment of prosecutors and law enforcement, rather than doctors and other healthcare providers who are more likely to know whether the treatment was necessary.
When prosecutors second-guess doctors about what is medically necessary, there are bound to be disagreements. Unfortunately, those disagreements come in the form of serious allegations of healthcare fraud. When the medical care was paid for by federally-funded programs like Medicare or Medicaid, those allegations lead to investigations by the Health and Human Services Office of the Inspector General (OIG) or the Centers for Medicare and Medicaid (CMS). In some cases, the Department of Justice (DOJ) is also involved, making the process and the accusations even more intimidating and raising the stakes even higher.
Falsifying Patient Records
In some cases, prosecutors claim that a healthcare provider not only provided unnecessary medical treatment in order to bill for it, but also falsified the patient’s medical records in order to make it seem like it was really necessary. Prosecutors may also claim that the patient’s records were changed or test results were skewed in order to support a different, more expensive, medical procedure.
These are serious allegations, and can sometimes amount to the crime of forgery. Disproving them can be difficult because the allegations call into question the veracity of the very documents that are often used in healthcare fraud defense.
Prescription Drug Fraud
In recent years, the Drug Enforcement Administration (DEA) and the DOJ have been closely monitoring the dispensation of controlled substances, particularly opioids. Political pressure after the opioid epidemic is partially to blame. That pressure to better enforce the law, though, has led to innocent healthcare providers being accused of a serious offense of prescription drug fraud.
Fraudulent Billing Codes
A common allegation of healthcare fraud has to do with the codes that are used to bill healthcare programs, especially Medicare and Medicaid. Medical care, treatment, procedures, and equipment has a specific code assigned to it. Getting creative with those codes, or intentionally using the wrong one, in order to increase the amount being billed is a common way of committing healthcare fraud. Some specific fraudulent practices include:
- Upcoding, or performing one medical procedure but billing for a similar, more expensive one
- Phantom billing, or charging for medical treatment that was never provided or for equipment that was never used or ordered
- Double billing, or charging for a single medical treatment multiple times
- Unbundling, or performing multiple medical procedures at the same time, but submitting a bill that codes them individually, at a higher price
Doing any of these billing or coding practices intentionally is healthcare fraud. But intent is a required element in many cases. If they only happened accidentally, they are merely billing errors. The difference can be huge.
Kickbacks and Illegal Referrals
Medical providers are limited in when they can refer patients to other medical professionals. A complex network of federal laws regulates when this can and cannot be done. Some of these laws even impose criminal liability on individuals or institutions.
False Claims for Treatment
Many of these other forms of healthcare fraud also violate the federal False Claims Act. This law forbids the submission of any false or fraudulent claim for reimbursement to a federally-funded program, including Medicare and Medicaid.
The civil penalties for a False Claims Act violation are substantial. Worse, they can be imposed for even inadvertent conduct. Intentionally submitting a false claim can lead to criminal liability and even jail time.
What Laws Will Govern a Case in Detroit?
The laws that will govern a healthcare fraud case in Detroit will depend on the source of funding for the program that was allegedly defrauded.
Federally-funded programs implicate federal laws. These programs include:
- Children’s Health Insurance Program (CHIP)
- Programs under the Veteran’s Health Administration (VHA) or the Indian Health Service (IHS)
When the alleged healthcare fraud involved funds provided by private or state health insurance companies, including the Michigan Medicaid Health Care Program (MMHCP), the case often moves forward under state law. For cases originating in Detroit, it generally means that the Michigan Medicaid False Claims Act (MMFCA) will govern the case.
The law enforcement agency will also change. Federal laws dealing with healthcare fraud can be enforced by the:
- Health and Human Services Office of the Inspector General (OIG)
- Centers for Medicare and Medicaid (CMS)
- Department of Justice (DOJ)
- Federal Bureau of Investigation (FBI)
- Drug Enforcement Agency (DEA)
If state law will govern the case, the Michigan Attorney General will prosecute it.
In some cases, a private individual will blow the whistle on alleged healthcare fraud and will pursue a qui tam claim against the provider, claiming a violation of a state or federal fraud law.
Why is Law Enforcement Focusing on Detroit?
These federal law enforcement agencies have been focusing on Detroit because of the high number of people in the city and region who are enrolled in federal healthcare programs, like Medicaid. With all of these patients come more claims for reimbursements from healthcare providers. In theory, the large volume of claims likely means that there are more fraudulent ones.
In response to this hypothetical fraud in areas with outsized Medicaid enrollment, the DOJ and OIG collaborated in May, 2009, to create a team of healthcare fraud investigators called the Health Care Fraud and Enforcement Action Team (HEAT). There are nine of these teams of investigators in the U.S., and one of them is based in Detroit.
The presence of this interagency group of investigators means that law enforcement has more resources at its disposal that are designated specifically to detect and prosecute healthcare fraud. Healthcare providers in the area are more likely to face allegations of fraud. Many of these accusations are groundless.
Frequently Asked Questions (FAQs)
Is healthcare fraud criminal or civil?
Healthcare fraud can lead to either criminal or civil liability, depending on the circumstances. The difference between the two is whether a conviction can lead to a jail or prison sentence. For example, violating the federal Anti-Kickback Statute (42 U.S.C. § 1320a-7b) is a crime. It is a felony offense that carries up to 5 years in federal prison, as well as a fine of $25,000 for each violation. The federal Stark Law (42 U.S.C. § 1395nn) only leads to civil liability, though that liability can be substantial – $15,000 in fines for every violation, and a fine of $100,000 if there was a scheme to circumvent the law. Claims under the federal False Claims Act (31 U.S.C. §§ 3729 – 3733) can be either civil or criminal in nature, depending on whether there was intent to defraud.
What kinds of penalties are there?
The penalties for a conviction of healthcare fraud will depend on the specific conduct at issue and the amount that was allegedly defrauded. However, the sanctions generally involve a mixture of steep fines, civil penalties, exclusion from the healthcare program, extensive monitoring of the provider in the future, and potentially even jail time. Providers who are convicted for healthcare fraud may also face professional repercussions, such as by having their medical certifications rescinded or by losing business due to the stain on their reputation.
What is a whistleblower claim?
A whistleblower claim is a civil lawsuit brought by a private citizen under the qui tam provision of the state or federal False Claims Act. This provision empowers private individuals – rather than the government or law enforcement – to blow the whistle on alleged healthcare fraud. The whistleblower can present evidence of fraud to law enforcement. In return, the whistleblower can recover a percentage of whatever is recovered, should the government take over the case. If the government decides not to intervene, the whistleblower can still pursue the fraud claim on their own. Unfortunately, the whistleblower is often a former employee or patient. Even if it is just an act of vengeance or retaliation, whistleblower claims are still serious matters that can lead to an extensive federal investigation that, even if it turns up nothing, is still a huge inconvenience.
Why does The Criminal Defense Firm not call themselves the best healthcare fraud defense lawyers?
The Criminal Defense Firm does not call itself the best healthcare fraud defense law firm because the legal field strictly regulates how law firms market themselves and lay claim to a specialty. Instead, we let our track record speak for itself. Nothing that we can say is more persuasive then the long list of success stories that we have brought for our clients.
Why Should I Hire The Criminal Defense Firm?
Healthcare providers in Detroit should strongly consider hiring an attorney as soon as they learn that they are being investigated for healthcare fraud. Getting legal representation as early as possible allows the defense team to conduct an internal investigation to get ahead of law enforcement. This allows the defense to get a better understanding of the facts of the case, see what the investigation will likely uncover, and prepare for the next steps.
But hiring just any criminal defense attorney for a healthcare fraud investigation is usually inadequate. Healthcare law is extremely complex, with intricate regulatory systems that require strict compliance. It is extremely important for the defense team to have extensive experience handling healthcare fraud claims. Even experience in white collar crime is usually not enough for an effective defense, given the unique regulatory framework of healthcare law in the U.S.
The Criminal Defense Firm is a law firm that is dedicated to defending healthcare providers against federal fraud charges. Our lawyers have decades of experience protecting individuals and institutions from both civil and criminal liability for healthcare fraud. Many of our attorneys are former healthcare fraud prosecutors who understand how fraud investigations work. This can help us predict law enforcement’s next move and see how to reach the best outcome for our clients, including those in Detroit. Contact our trusted team today.