Medicaid Early and Periodic Screening Fraud Defense

Knowledgeable Attorneys for Medicaid Early and Periodic Screening Fraud Defense

Proven Legal Representation for Providers that Face EPSDT Fraud Allegations

The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit is a critical component of Medicaid, ensuring that children and adolescents receive medically necessary healthcare services. For providers, participating in EPSDT offers a vital opportunity to serve vulnerable populations while receiving appropriate reimbursement. However, the complexity of the program’s requirements can often lead to administrative misunderstandings or targeted investigations.

In an era of heightened transparency, EPSDT providers are facing unprecedented oversight. Investigative bodies, ranging from CMS-contracted fee-for-service auditors to the Department of Justice (DOJ) and Medicaid Fraud Control Units (MFCUs), are increasingly aggressive in pursuing perceived improper payments. When your practice is under the microscope of the HHS Office of Inspector General (OIG), securing an elite Medicaid fraud defense is paramount to protecting your professional standing.

Comprehensive Defense Strategies Against Medicaid EPSDT Fraud Claims

Our firm is dedicated to shielding Medicaid providers from the severe repercussions of healthcare fraud allegations. We understand that a federal investigation can be overwhelming, threatening both your reputation and your livelihood. Our approach is proactive and sophisticated, leveraging every available legal tool to resolve claims efficiently and favorably.

Our legal team provides professional advocacy for healthcare entities in complex Medicaid fraud matters.

Fraudulent Medicaid Billings Related to the False Claims Act

The False Claims Act (FCA) is the government’s primary weapon against improper billing. While unintentional errors can result in substantial civil penalties and treble damages, evidence of “willful” misconduct can escalate a case into a criminal prosecution. Navigating the fine line between administrative oversight and actionable fraud requires a nuanced understanding of federal billing statutes.

Defending against FCA allegations regarding EPSDT payments often centers on the strength of your internal compliance program. Our attorneys conduct rigorous assessments of your billing practices to identify and rectify vulnerabilities. 

Whether by demonstrating good-faith compliance with regulations or by aggressively challenging the government’s interpretation of “fraud,” we strive to preserve your ability to continue serving Medicaid patients without the shadow of federal charges.

Anti-Kickback Statute and Stark Law Violations

The integrity of healthcare referrals is strictly governed by the Anti-Kickback Statute (AKS) and Stark Law. These regulations prohibit the exchange of anything of value in return for Medicaid or Medicare referrals. For providers, even seemingly standard business arrangements can be misconstrued as unlawful remuneration, resulting in significant civil or criminal exposure.

We assist organizations in auditing their referral networks and compensation structures to ensure full compliance. If you are targeted for an enforcement action, we work tirelessly to dispute the government’s evidence and demonstrate that your practices fall within the safe harbors of federal law, protecting your business from the catastrophic consequences of an AKS or Stark Law violation.

Other Types of Healthcare Fraud

Investigations that begin with EPSDT often expand in scope. Federal agents look for systemic “red flags” in Medicaid data that may suggest broader patterns of abuse. It is essential to approach every audit with a comprehensive strategy, as a single inquiry can quickly evolve into a multi-faceted investigation of your entire billing history and practice operations.

This includes scrutiny that could lead to allegations of:

Behavioral Healthcare Fraud

Behavioral health has become a high-priority area for Medicaid enforcement. Inconsistencies between medical records and billing claims can result in allegations of overutilization or billing for services not rendered. We defend mental health providers by ensuring their clinical documentation justifies the services billed, mitigating the risk of recoupment or exclusion.

Community-Based Services Related to Fraud

The utilization of community-based services is under rigorous scrutiny for eligibility and coding accuracy. Claims for services to ineligible patients or for noncompliance with administrative rules can trigger severe penalties. We provide clear, evidence-based defenses to protect providers from allegations of systemic exploitation in this sector.

Durable Medical Equipment (DME) Fraud Claims

DME suppliers and prescribing physicians are frequently targeted for coding errors or providing equipment to patients who do not meet medical necessity criteria. Whether the issue is an honest clerical mistake or an intentional violation, we advocate for DME stakeholders to prevent exclusion from federal healthcare programs.

Home Health Care Fraudulent Billings

Home health care remains a top enforcement priority due to the potential for fraudulent billings and improper referral fees. Agencies facing audits must demonstrate strict compliance with statutory and regulatory requirements. Our defense strategies focus on technical accuracy and clinical necessity to counter aggressive government claims.

About Our Medicare and Medicaid Fraud Defense Practice

Our knowledgeable defense practice comprises seasoned attorneys who represent a diverse array of healthcare entities. From hospitals and private clinics to laboratories and managed care organizations (MCOs), we represent all participants in the federally funded healthcare landscape facing scrutiny under Medicare and Medicaid.

We draw upon deep institutional knowledge and extensive experience defending against fraud, waste, and abuse allegations. Our national network of trial lawyers and compliance experts allows us to provide localized support with the resources of a premier federal practice, ensuring your defense is both assertive and precision-targeted.

For healthcare providers and organizations participating in the EPSDT program, our firm offers a full suite of professional legal services designed to address the challenges of federal oversight. 

Our comprehensive defenses and advocacy include:

• Strategic Medicaid Audit Defense: We develop proactive strategies to manage audits from CMS-contracted fee-for-service auditors and other program integrity entities, ensuring that your clinical documentation accurately supports your billings.
• Fraud Investigation Advocacy: Our team provides an aggressive defense during investigations led by the HHS Office of Inspector General (OIG), the Department of Justice (DOJ), and state Medicaid Fraud Control Units (MFCUs).
• Administrative and Civil Enforcement Defense: We protect providers against severe civil repercussions, such as financial recoupments, treble damages, and potential exclusion from federal healthcare programs under the False Claims Act.
• Criminal Medicaid Fraud Representation: In cases where allegations escalate to charges of “willful” misconduct, we offer elite criminal defense to shield your liberty and your professional future.
• Professional Disciplinary Action Defense: Beyond financial and criminal penalties, we advocate for professionals facing licensing and disciplinary challenges that threaten their ability to practice.

We also provide comprehensive Medicaid compliance services; if your practice or business is facing scrutiny related to a Medicaid billing compliance failure, we can help ensure your personnel do not make similar mistakes going forward. To learn more about how we can help, contact us for a free and confidential consultation today.

FAQs: How are Fraud, Waste, and Abuse Allegations Fought Under Medicaid?

Q: Which agencies in the federal government investigate Medicaid fraud?

If you receive a federal agent contact or an audit notice, your priority is to engage experienced legal counsel immediately. Do not attempt to respond to inquiries or provide documents without legal guidance. 

Ensure that all internal records, patient files, and billing data are preserved; do not delete or alter any files. Also, exercise your right to have counsel present during any interviews or meetings with investigators, and avoid discussing the investigation with colleagues or on social media.

Q: When do Medicaid providers face liability under the Anti-Kickback Statute and Stark Law?

Providers can face liability if they willfully solicit, receive, offer, or pay any form of remuneration, including cash, kickbacks, or gifts, in exchange for patient referrals. The Anti-Kickback Statute and Stark Law prohibit using federal funding to induce or reward referrals. Even inadvertent violations or poorly structured business arrangements can trigger scrutiny and severe civil or criminal penalties.

Q: What penalties are assessed for the improper billing of Medicaid under the EPSDT program?

The penalties for improperly billing Medicaid under the EPSDT program depend on whether federal authorities decide to pursue civil or criminal charges. In civil cases, providers and other businesses can face financial penalties (e.g., fines, recoupments, and treble damages), as well as the possibility of Medicaid exclusion. In criminal cases, prison time is on the table.

Q: What if my practice improperly billed Medicaid, without intent, under the EPSDT program?

If you discover that your practice has submitted improper billings, it is critical to take proactive steps rather than waiting for an audit. This may involve conducting an internal compliance audit to quantify the overpayment and considering self-disclosure protocols to resolve the issue.

Working with experienced healthcare counsel can help you determine the most appropriate approach to correcting the errors, minimizing liability, and protecting your practice from aggressive enforcement actions.

Schedule a Free and Private Consultation with a Medicaid Fraud Defense Lawyer Now

If your practice is facing a Medicaid audit, an investigation, or a formal enforcement proceeding regarding the EPSDT program, immediate action is your best defense. Do not navigate this complex legal terrain alone. Call (866) 603-4540 or reach out online to schedule a confidential case evaluation with our healthcare defense team.

Last Updated: 08-25-2026