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False Claims and Regulatory Defense

Trade groups estimate that as much 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 together 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, providers who find their business practices scrutinized are at a distinct disadvantage.

Without deep pockets and the right connections, most providers simply cannot mount an adequate defense. Our experience in health law combined with an intimate knowledge of the civil and criminal process means that we can provide aggressive, skilled, and cost-efficient representation for providers accused of improper billing or other regulatory violations.

This experience has led to our successful defense of the rights of providers and their practice groups accused of billing fraud and other criminal offenses in federal and state courts and administrative hearings, and in actions initiated by the Department of Justice and the New Jersey Office of the Attorney General.

Defending False Claims Act and Civil Insurance Fraud Claims

Our civil litigation 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 allegations for which we have successfully defended our clients include:

  • Billing for medical care that was never provided
  • Filing duplicate claims for the same service
  • Altering the date 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

Defending Allegations of Healthcare Fraud and Other Healthcare Crimes

Unfortunately, many of the same allegations we routinely defend in civil fraud litigation are increasingly forming the basis of both state and federal criminal complaints. Our criminal practice focuses on defending healthcare providers in state and federal prosecutions for a variety of healthcare-specific crimes.

Beyond the underlying gravity of a criminal prosecution, we understand the significant impact that a criminal prosecution, even if resolved positively, can have on licensed professionals. As such, we counsel our clients on the ancillary consequences of criminal prosecutions and resolutions, including but not limited to navigating the pitfalls of exclusion by DHHS and disciplinary proceedings before professional licensing boards.

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.

Defending Allegations of Professional Misconduct

Licensing board complaints may be filed by disgruntled patients, their family members, other healthcare providers, former employees, or anyone who interacts with a particular provider. An increased awareness of the professional discipline process, aided by consumer groups and state laws that require posting patient bills of rights in waiting rooms and the development of streamlined reporting processes, including online complaint forms, have led to a dramatic increase in the number of complaints filed.

We have successfully defended individual providers before the New York State Office of Professional Discipline, the New Jersey Department of Health, the New Jersey State Board of Medical Examiners, the New Jersey State Board of Chiropractic Examiners, the New Jersey State Board of Nursing, the New Jersey State Board of Physical Therapy, the New Jersey State Board of Dentistry, the New Jersey State Board of Social Work Examiners, and the New Jersey State Board of Pharmacy. Our job is to protect your reputation and your livelihood when you face discipline and to ensure you are managing and complying with risks effectively.

  • Posted on: Feb 22 2023