Protecting Healthcare Professionals Accused of Criminal Wrongdoing

Trade groups estimate that as many as 10 percent of all healthcare spending in the United States is lost to fraud and abuse. We’ve seen the increased scrutiny of payments made to healthcare providers grow hand-in-hand with fraud and misappropriation laws that have evolved from narrow measures aimed at stopping intentional theft in the traditional sense to expansive rules and regulations that include a broad range of unintentional acts. As a result, physicians and other healthcare providers who find their business practices scrutinized are at a distinct disadvantage.

A Growing Trend in Law Enforcement and Regulation

Law enforcement officers at all levels of government are charged with investigating and prosecuting insurance fraud. From the federal level, where the FBI and Office of the Inspector General for the Department of Health & Human Services are tasked with investigating Medicare and Medicaid fraud, to state and local law enforcement officers charged with examining insurance scams, antifraud funding has risen and prosecutions are intensifying.

Traditionally—and unfortunately—without deep pockets and the right connections, most providers simply cannot mount an adequate defense. Our experience in healthcare law combined with an intimate knowledge of the criminal justice process means that we can provide aggressive, skilled, and cost-efficient representation for providers accused of improper conduct. This experience has led to successful defense of the rights of providers accused of criminal offenses or other violations in federal and state courts and administrative hearings.

Changes in Insurance Reimbursement Have Increased Prosecution

Our healthcare criminal defense practice includes a special emphasis on the investigation and defense of complex insurance fraud allegations arising from the submission of reimbursement claims by healthcare providers. Some of the criminal allegations for which have successfully defended our clients include:

  • Billing for medical care that was never provided
  • Filing duplicate claims for the same service
  • Altering the dates services were provided
  • Falsifying the description of services provided
  • Changing identities of members or providers
  • Failing to keep proper records
  • Accepting or giving kickbacks for member referrals
  • Waiving member co-pays
  • Prescribing additional or unnecessary treatment
  • Billing a non-covered service as a covered service
  • Modifying medical records or intentionally and incorrectly reporting diagnoses or procedures to maximize payment
  • Using unlicensed staff or selling unproven remedies
  • Using equipment improperly

We also provide representation prior to the filing of criminal charges during preliminary law enforcement investigations or a grand jury proceeding. We have avoided the filing of any charges or influenced the filing of lesser charges. Our preferred strategy is “early intervention,” which focuses on building a strong defense before formal charges are filed while fully cooperating with investigating authorities in the hopes of amicably resolving unsubstantiated allegations.