Healthcare Audits and Investigations
Our Health Law Group assists health care providers, insurance companies, clearinghouses, supply companies, and all related business associates defend against charges and allegations of health care fraud.
Fraud audits by providers can affect all aspects of your practice and can also increase deductibles, co-pays and insurance premiums.
We assist our clients through audits, federal and state government investigations, and all other compliance needs. If you have been accused of fraudulent activity, been put under investigation, or are currently undergoing an audit, call us now.
What is a Healthcare Fraud Audit?
There are millions of health care insurance claims that are submitted to companies that help make it more affordable to retain quality care.
A small percentage of these millions of claims are fraudulent, and this percentage costs Americans an estimated tens of billions of dollars annually. This leads to higher premiums and out-of-pocket expenses.
Healthcare fraud cases usually are by a few dishonest care providers that are negligent with the patients’ best interest in mind. Healthcare fraud occurs in various situations, from obtaining a patient’s personal medical records to create and submit false claims, and duplicating tests and procedures that are unnecessary.
The Most Common Types of Health Care Fraud According to NHCAA
According to the National Health Care Anti-Fraud Association (NHCAA), the most common types of fraud are:
- Medically unnecessary services performed to generate payments from insurance
- Patient’s diagnoses that are falsified in order to bill for tests, procedures or surgeries that are medically unnecessary
- To obtain insurance payments for non-covered treatments as in “nose jobs” that are medically unnecessary under deviated-septum repairs.
- Never rendered services that are billed either by using a patient’s information that was obtained from identity theft to fabricating claims or padded claims for procedure and service claims that never took place.
- Overbilling benefit plans or insurance carriers, or waiving co-pays and deductibles for patients.
- Expensive procedures or services that were billed that were provided or performed at a lesser rate which is known as “upcoding.” Upcoding is explained as billing higher-priced treatment than the lesser provided or performed procedure. This consists of using a more serious condition code that is consistent with a procedure code that in invalid.
- They are billing each step of a procedure instead of bundling into one procedure.
- Patient referrals that create kickbacks
- Prepaid or paid in full services in excess of the patient’s co-pay amount by the benefit plan.
Typically, Medicare fraud includes:
- Submission of false claims or misrepresentations of fact either knowingly or causing it to be submitted.
- Inducing or rewarding referrals for services or items that are reimbursable services by knowingly offering, paying remuneration, receiving, and soliciting
- Giving referrals for certain designated health services that are prohibited.
Abuse of Erroneous Claims
Abuse of erroneous claims consists of unnecessary cost practices that result either directly or indirectly is considered abuse of the Medicare Program. Abuse includes medically necessary services that are inconsistent services meeting professionally recognized standards.
- Unnecessary billing for medical services
- Excessive charges for services or supplies
- Upcoding or unbundling codes on a claim can expose providers to civil and criminal liability.
Who Can Be Found Liable for Health Care Fraud?
All healthcare facilities and healthcare providers that provide medical services are billed to insurance companies including Medicare and Medicaid.
The statutes and acts that define fraudulent or abusive claims consist of:
Federal False Claims Act (FCA)
The Federal False Claims Act (FCA) protects the Federal Government from being overcharged or sold substandard goods or services. The penalties imposed on any person who submits or causes the submission of false or fraudulent claims.
Anti-Kickback Statute (AKS)
The Anti-Kickback Statute (AKS) makes it a crime to offer, solicit, pay, or receive any remunerations either knowingly or willfully to induce or reward referrals of reimbursable services and items.
Physician Self-Referral Law (Stark Law)
The Physician Self-Referral Law (Stark Law) prohibits a physician from referring to certain designated health services to an entity in which they or family members have an ownership/investment interest that is usually payable by Medicare or Medicaid.
Criminal Health Care Fraud Statute
The Criminal Health Care Fraud Statute prohibits executing, or attempting to execute either knowingly and willfully, or attempting to complete, an artifice or scheme or artifice connected to the payment or delivery on benefits, services or items. This includes:
Any health care benefit program that is defrauded
Obtaining any money or property that is owned by or under control of these programs either by representations, false or fraudulent pretenses, or promises
Civil Monetary Penalties
Civil Monetary Penalties are authorized for a variety of health care fraud violations. CMPs can also include an assessment of up to three times the remuneration paid, received, offered or solicited and amounts claimed for each service or item.
CMPs may use these violations:
A claim for an item or service not provided either knowingly or should have known that is claims or fraudulent and false
A claim for an item or service that is not payable by Medicare either knowingly or should have known
It is a federal criminal offense to commit healthcare fraud and abuse, and there are significant penalties attached to it.
If you are found guilty of healthcare insurance fraud, there is a sentence of up to 10 years in a federal prison including substantial monetary fines.
If a patient became injured due to false claims, the violator would be convicted, and the imprisonment period can double up to 20 years.
If the patient died as a result of the fraudulence, the violator could be sentenced to life in prison.
Who is in Charge of Health Care Audits?
There are audits for many different types of services, coverage, and policies. They consist of the following.
Recovery Audit Contractor (RAC).
Recovery Audit Contractors are required to have certified coders, medical directors and a way for physicians to review the status of their audits. The contingency fees must be paid back to RAC if an appeal is lost. RAC must first send results of the audited providers prior to sending audit results to CMS.
The audited provider then has 30 days to send a request to discuss the results and can also send in additional documentation or information to support their interpretation of requirements by Medicare.
Medicaid has strengthened their program through three new initiatives which include boosting efforts to ensure compliance of federal rules, greater oversight of contracts between private insurers and states, increase audits, and greater oversight of eligibility of the beneficiary. In 2013, the spending on Medicaid increased from $456 billion and in 2016 an estimated $576 billion.
Zone Program Integrity Contractors (ZPIC)
Zone Program Integrity Contractors (ZPIC) and Program Safeguard Contractors (PSC) state that they are not bounty hunters like their Recovery Audit Contractor (RAC) counterparts. CMS pays ZPICs on a contractual basis instead of on a contingent fee like RACs.
If ZPICs are not successful in identifying alleged overpayments, then their chances of renewing their contract have diminished.
ZPICs use sophisticated data mining techniques to identify health care providers and physicians whose utilizations, coding or billing behavior that is not the same as their other peers. There has been an increase in the number of referrals made by ZPIC to state licensure boards of the providers.
The “Comprehensive Error Rate Testing” (CERT)
The “Comprehensive Error Rate Testing” (CERT) program is a tool to assess whether Medicare Administrative Contractors (MACs) are paying their claims properly for the Centers for Medicare and Medicaid Services (CMS).
CERT audits are an integral management tool for CMS and provide a feedback mechanism for the MACs. If there are problems, Medicare contractors with audit responsibilities will address them.
How Are Healthcare Fraud Investigations Carried Out?
The Complex Financial Crime Program through the Federal Bureau of Investigations (FBI) expose and conduct investigations of health care fraud with investigative partnerships consisting of other federal agencies, such as:
- Drug Enforcement Administration (DEA),
- Food and Drug Administration (FDA),
- Defense Criminal Investigative Service (DCIS),
- Health and Human Services-Office of Inspector General (HHS-OIG),
- Internal Revenue Service-Criminal Investigation (IRS-CI), and
- Office of Personnel Management-Office of Inspector General (OPM-OIG),
- along with various state Medicaid Fraud Control Units and other state and local agencies.
How Can I Help Prevent Health Care Fraud?
Some of the most common methods used to obtain patient insurance information:
Providing gift or money to individuals visiting a location where they sign in, and their identities are obtained.
When a patient obtains a free screening at health fairs, patient information is disclosed.
Patient insurance information received by medical personnel to copy the provide information to those involved in fraud schemes.
Information that was purchased from other fraud violators including fraudulent company owners and marketers that have in their possession of stolen patient and physician billing information.
In order to determine if your insurance information has been compromised, review your explanation of benefits (EOB) that you receive from your insurance company. These EOBs lists all services and supplies that were billed by your medical provider. If you suspect that they billings are inaccurate, contact your insurance company immediately.
How to protect yourself during a healthcare audit?
Safeguarding benefit information and insurance cards. Be vigilant if your information is requested. Avoid free services and telemarketing calls that require this information. Only provide your insurance card or insurance information to others that are providing services.
Don’t accept gifts or other items including unnecessary equipment or products from other medical providers. Report any suspicious or unusual activity.
Be sure to check the medical supplies received with what was ordered. For example, receiving a cheaper scooter over an order power wheelchair.
Be aware of your surroundings in medical facilities. For example, be aware of medical offices that lack normal medical equipment when completing a physician visit If personnel fail to conduct normal patient health checks as in your vitals and weight, then you are likely to become a victim of fraudulent claims.
Looking for a Health Care Fraud Attorney? Call Us Now
Health care fraud can have a devastating impact on you, your family, government, insurance providers and state agencies. That is why you need an experienced health care fraud audit attorney.
Our attorneys understand the healthcare industry and can help you understand the charges that are being brought against you. We can accompany you to interrogations and ensure that your rights are not violated. Ultimately, our goal is to help you establish a legitimate defense.
We have the knowledge and background to successfully defend anyone prosecuted for healthcare and insurance fraud in both state criminal and civil proceedings and federal criminal and civil proceedings.
We have represented industry and corporate clients, doctors, pharmacists, administrators, clinics, hospitals, and other health care industry, professionals.
If you or someone you love has been charged with health care fraud related to improper billing, call our attorneys for a free legal consultation.