Los Angeles Healthcare Attorneys
In such a heavily regulated industry as the healthcare industry, it’s critically important that practitioners, professionals and healthcare executives have legal counsel experienced in matters related to the health care industry. The attorneys at the Health Law Group can help identify any potential risks, negotiate corporate transactions and to provide strategic representation and advocacy in complex litigations and potential criminal proceedings.
With experience in all aspects of healthcare law, the attorneys at the Health Law Group represent client interests in a wide array of litigation, regulatory, employment and criminal related matters. Our lawyers have helped many clients resolve some of the most complex legal issues including corporate structure, merger and acquisitions, government regulations and state and federal fraud abuse matters.
Our Los Angeles law office provides legal counsel to healthcare providers including hospitals, physicians, treatment centers, clinics, dental offices and more. We understand the unique challenges that pharmaceutical manufacturers and durable medical equipment manufacturers face. Our healthcare lawyers can assist advise you on a number of legal issues including but not limited to:
Internal audits and investigations
Medi-Cal Fraud and other Health Care Fraud issues
Health care fraud is an issue that may be prosecuted at both the state and federal levels. Our attorneys in Los Angeles have the experience and knowledge necessary to help defend you against both state and federal charges.
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As Los Angeles healthcare fraud attorneys, we have defended healthcare fraud cases to great success over the years. Our team possesses the knowledge and experience necessary to stand up to prosecutors at both the state and federal level.
Due to its enormous financial impact and the risk it poses to patient safety, efforts to eradicate healthcare fraud are on the rise in Los Angeles. Healthcare fraud can take a number of different forms.
Below are a few common examples of health care fraud in Los Angeles:
- Giving or accepting illegal kickbacks in exchange for patient referrals.
- Billing insurance plans for services that were not provided.
- Exaggerating the need for an expensive treatment.
- “Upcoding” provided services on insurance claims in order to receive more reimbursement than you are entitled to.
- Recommending patients for prescriptions or procedures that are not medically necessary.
- Knowingly working with healthcare professionals excluded from government benefit plans.
- Billing for services performed by unqualified healthcare professionals.
- Billing separately for services traditionally performed as a single service.
- Promoting a drug for purposes beyond its FDA approved purpose.
- Prescribing unnecessarily expensive medications or billing for unnecessarily expensive procedures for the purpose of increasing insurance reimbursements.
- Falsifying patient records to justify unnecessarily performed procedures or prescribed medications.
While many of the cases of healthcare fraud that make the news involve multi million dollar schemes, healthcare providers have lost their careers and reputations for far less.
If you have committed healthcare fraud, it is imperative that you consult with a criminal defense attorney immediately.
Federal Healthcare Fraud Charges
If you are charged with a healthcare fraud violation, your conduct may be punishable under a number of different federal statutes.
Penalties can range from minor fines to decades in prison.
Below is a brief overview of the federal statutes you could be charged under if you have committed healthcare fraud.
The Federal Healthcare Fraud Statute: 42 U.S.C. §1347 punishes by fine and/or up to 10 years in prison the knowing and wilful execution of a scheme to:
The False Claims Act: When a doctor bills for services that are unnecessary or undelivered, falsely reports patient symptoms or diagnoses, or misrepresents his qualifications, the False Claims Act could be triggered. Violations, including upcoding, bundling, and billing for unnecessary services are covered by the Act. The specific statutory language reads:
“Whoever makes or presents to any person or officer in the civil, military, or naval service of the United States, or to any department or agency thereof, any claim upon or against the United States, or any department or agency thereof, knowing such claim to be false, fictitious, or fraudulent, shall be imprisoned not more than five years and shall be subject to a fine in the amount provided in this title.”
Successfully reaching a conviction under the act requires proof of each of the following elements beyond a reasonable doubt:
- The defendant presented a claim to a department of the United States that was either false, fictitious, or fraudulent;
- The defendant had knowledge that the claim was false, fictitious or fraudulent; and,
- The defendant’s specific intent was to violate the law, or the defendant had consciousness that what he was doing was wrong.
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This often occurs when a healthcare provider requests reimbursement of medical goods or services from a healthcare benefit plan that were in fact either not provided, not provided as stated, or provided, but not medically necessary.
Penalties are often more severe when the benefit plan defrauded is government run, such as when false reimbursement claims are submitted to Medicare or Medicaid. However defrauding private insurance plans can be penalized as heavily as defrauding public ones can, depending on the severity of the conduct.
While healthcare providers are afforded a great deal of discretion in how they use their medical judgment, failure to conform to the customary medical industry norms can attract attention and give rise to criminal liability. Penalties upon conviction can extend up to 5 years in prison
The False Statements Act: The False Statements Act applies to communications to the government which contain false statements, representations, writings, or documents, or that in any way falsify or cover up a material fact.
In other words, the False Statements Act applies when a healthcare provider submits a bill for a procedure that he never actually performed, or submits false documentation of an injury the patient does not indeed have.
The elements of a False Statements Act violation are similar to an FCA violation, in that the prosecution must prove:
- The statement directly or indirectly submitted to the federal government was false.
- The defendant intentionally submitted the statement with knowledge of its falsity, and
- The statement was material to the business of the government agency or department.
Regarding the third element, to say that the statement was “material” simply means that the statement was of a type likely to influence the agency’s action.
So a false statement claiming that the patient was suffering from back pain would likely be considered material if the intent was to gain insurance coverage of physical therapy, whereas it might not be considered material in a claim for reimbursement of psychiatric treatment. Penalties can extend up to 5 years in prison upon conviction.
The Social Securities Act: Provisions 42 U.S.C. S1320a-7b(a) specifically concern cases where false statements are made connection with services covered by a federal healthcare program. “Federal healthcare program” is defined as any state health care program receiving federal funds. Penalties can extend up to 5 years in prison.
Anti-Kickback Statute: Kickback relationships promote bias and interfere with a doctor’s ability to prescribe medications and recommend procedures that serve the patient’s best interests. Whether you are a psychiatrist receiving compensation from the mental health clinic you refer your patients to, or an anesthesiologist accepting restaurant gift certificates from an opiate manufacturer, it is illegal to accept compensation in exchange for promoting another provider’s products or services.
Under 42 U.S.C. 132Oa-7b(b) any such exchange that occurs “knowingly” and “willfully” is criminally prohibited.
While “safe harbor” regulations exempt certain kinds of kickbacks, our criminal attorneys can help you prevent potential liability by clarifying precisely what you are permitted to do and not to do.
Healthcare providers engaged in kickback relationships often refer patients for unnecessary tests administered by facilities they have a relationship with, or prescribe unnecessary medications manufactured by companies that pay them in goods or services.
Accordingly, anti-kickback violations are often part of a more elaborate scheme involving conduct prohibited by the False Claims Act and False Statements Act. Penalties can extend up to 5 years in prison.
Federal Mail and Wire Fraud: Because medical claims are often submitted electronically or by mail, healthcare fraud charges can also be brought under 18 U.S.C. §1341, §1343. Penalties can extend up to 5 years in prison.
Federal Theft or embezzlement: 18 U.S.C. §669 prohibits conduct in which the assets of a healthcare program are intentionally misapplied, or knowingly and willfully converted. Penalties can extend up to 10 years in prison.
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California State Healthcare Fraud Charges:
In addition to federal charges, if you have committed healthcare fraud in Los Angeles you may face charges under under California law. One charge you might face is Medi-Cal fraud.
Medi-Cal is California’s need-based benefit program which offers free and/or reduced-cost health insurance to those of limited financial means. Qualification depends on factors such as income, residence, age, health condition, among others.
Patients can commit Medi-Cal fraud by falsifying eligibility criteria, but the most impactful forms of Medi-Cal fraud are committed by healthcare providers, who are in the position to defraud California of far more tax dollars, as well as to jeopardize the health of patients.
Below are just a few of many examples:
- Biling Medi-Cal for medically unnecessary services.
- Billing Medi-Cal for services you never provided.
- Billing Medi-Cal for more expensive services than those you actually performed.
- Recommending more expensive services than the patient actually needed.
- Engaging in kickback relationships with regard to Medi-Cal billing referrals.
Because Medi-Cal fraud steals billions of tax dollars from California per year, it frustrates the purpose of the program by depriving eligible individuals of the funding they need.
Medi-Cal fraud also puts patients at risk because it consumes their time, money, and attention with unnecessary healthcare services, thus robbing them of the opportunity to treat the conditions they suffer from.
In some cases, Medi-Cal fraud exposes patients to dangerous treatments and procedures that could worsen the conditions they are seeking medical assistance for in the first place.
Detection, Investigation, and Prosecution:
Both state and federal initiatives are aggressively targeting all forms of healthcare fraud, including Medi-Cal fraud. You should accordingly seek legal assistance immediately if you think you have exposed yourself to criminal liability.
Detection efforts are wide ranging and highly effective. Below is just a brief summary of how your conduct may be uncovered.
Whistleblower Incentives: The False Claims Act incentivizes people who have evidence of health care fraud to report it. By allowing “whistleblowers” to serve as plaintiffs in suits against wrongdoers, such individuals can obtain considerable financial rewards.
Because retaliation against whistleblowers exposes the accused to additional criminal liability, employees and colleagues with knowledge of your fraudulent conduct have no reason beyond loyalty to refrain from coming forward with allegations against you.
Government Investigation: The Health Care Fraud Unit of the Department of Justice is dedicated entirely to health care fraud investigation. In addition, the Office of the Inspector General and the US Department of Health and Human Services are using data analysis advances to assess trends in claims submitted to Medicare and Medi-Cal. By comparing the amount of claimed services performed by physicians to national norms, for instance, fraudulent patterns can be flagged for further review.
Once investigators have sufficient evidence to justify legal action, you may be placed under arrest, or a search warrant may be obtained against you.
Before this point, undercover DEA agents may come into your practice posing as patients, you may receive phone calls, letters, or legal documents requesting information, or investigators may openly attempt to question you at your home or work.
The more prepared you are for these moments, the better. Many of our clients reached out in a panic after they were formerly arrested, or during the course of a search warrant they knew would reveal incriminating evidence.
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Our Legal Services:
The best case scenario occurs when clients reach out before their situation reaches a crisis point. When you hire us on retainer, not only do you have us on call in case of emergency, you also have the knowledge and preparation you need to respond to law enforcement in a way that serves your best interests.
However if you do end up needing us, an investment in our criminal attorneys is widely considered by our clients to be the best money they’ve ever spent. Facing the possibility of decades behind bars, devastating fines, permanent loss of their medical licenses and irreparable damage to their reputations and families, the dramatic results we are able to achieve for our clients are frequently referred to as priceless.
Whatever the potential consequences you face, our job is to reduce them more than you dreamed possible.
In many cases, we are able to take the possibility of jail off the table for clients who thought it was inevitable. We have also achieved an impressive record of dismissed charges, often right at the start of a case.
Getting your case dismissed is the best case scenario, because it removes the expense of hiring experts, calling witnesses, amidst numerous other significant trial costs. While this is our goal for you, we pursue it by preparing your case as if you are going to trial.
This work ensures that, should dismissal not occur, you have the best possible options to choose from. Whether that’s a high chance of success in the courtroom or a better plea deal than you could have imagined.
Our strategy involves highlighting where the prosecution’s case is weak and where our case is strong.
It also involves demonstrating the full story of who you are, beyond the conduct you are charged with. In other words, our criminal defense attorneys become experts not just on every detail of your case, but on your personal story.
In doing this, we are able to show up for every conversation with the prosecution with the preparation and knowledge we need to make your case stand apart from the others.
Whatever destination this approach results in, you can count on our counsel reducing or eliminating the fines, jail time, impact on your criminal record and overall effect on your life you would have experienced without us.
While defending our clients against healthcare fraud violations is our primary focus, we are a full service firm available to meet all of your legal needs as a healthcare provider.
If you are facing the possibility of bankruptcy or civil liability, we can assist you in resolving those matters, and we are also skilled and experienced in mergers and acquisitions.
Los Angeles Healthcare Fraud Cases:
Healthcare fraud charges can be devastating, as the below examples demonstrate.
In 2017, of the largest federal healthcare fraud takedown in history occurred in LA. 14 defendants were charged with taking part in healthcare fraud schemes that resulted in $150 million dollar losses. Illegal kickback relationships and unnecessary billing of expensive compounded drugs, home health services, physical therapy, acupuncture, Medicare Part D prescription drugs, diagnostic sleep studies, and hospice care contributed to the extraordinary damage amount.
One of the defendants, Dr. Jeffrey Olsen, was charged with illegally prescribing oxycodone and other controlled substances, as well as lying on his DEA application. Olsen had sold the drugs to addicts directly in exchange for cash fees up to $3000, both in and out of state, often without ever meeting the patient.
Similarly, two other defendants were charged with fraudulently billing TRICARE for $4.8 million after they authorized prescriptions for patients they never met.
Another defendant, Aniceto Baliton who co-owned a hospice center, was charged with taking part in a kickback conspiracy. Balitan generated the cash for the kickback payments by documenting the amounts as payroll expenses. The scheme resulted in $2.4 million in fraudulent Medicare bills.
Finally, pharmacy owners Aleksandr Suris and Maxim Sverdlov were charged with executing a scheme which brought in over $40 million from Medicare and CIGNA. The defendants fraudulently billed for prescription drugs which were never filled.
These examples offer just a glimpse at the forms healthcare fraud can take, and the necessity of obtaining competent counsel as soon as possible.
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What To Do if you Suspect You’re Under Investigation:
Consulting with a white collar criminal defense attorney is your best course of action as a healthcare provider, whether or not you are currently facing charges.
Perhaps you’re unsure if your conduct has been criminal, or you’re thinking about participating in a plan that could give rise to liability. You might even just be uncertain of how to avoid facing criminal charges, and want to make sure that you are running your practice in perfect accordance with the law.
Our counsel can offer you the peace of mind in knowing that you are doing everything in your power to protect yourself.
Our specialty is helping clients out of unfortunate circumstances, but we love to help our clients avoid these circumstances in the first place.
We are available to help you establish a compliance program that protects you against being held vicariously liable for your employee’s actions, and are on call to counsel you through any legal questions you may have regarding how to run your practice.
If you have already engaged in criminal behavior, knowledge of your rights and responsibilities can save you from inadvertently making your situation worse.
Too often our clients have expressed deep regret that they did not get in touch with us sooner, after investigators uncovered lies they told at the beginning of an investigation, when they were caught off guard and didn’t know what else to do.
Do not let this happen to you.
Such snap decisions give rise to additional obstruction of justice charges which can both severely limit the opportunities of a case and also add years to an already severe sentence.
As time goes on, healthcare fraud detection, investigation, and prosecution in Los Angeles will only become more aggressive.
Even if you have carried on a lucrative scheme for years, for the vast majority of even the most sophisticated fraudsters criminal liability is inevitable.
Remember, there is no risk attached to your free consultation.
Our counsel is entirely confidential and ethically bound to serve your best interests. At the very least, we hope you will take advantage of our offer to help you obtain a personalized understanding of how healthcare fraud can affect you.
Whether it’s next month, next week, or even today, know that we are here when you need us, and never hesitate to give us a call.