Three Situations to Hire a Medical Fraud Attorney

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By Kaleem Ullah

Healthcare law and regulations are often complex and difficult to keep up with, particularly when new legislation changes the way claims can be made for programs like Medicare or other health insurance billing. If the time comes when you or your practice have been accused of healthcare fraud or abuse, you may need the guidance of medical fraud attorneys to help you navigate your case.

Three Situations to Hire Medical Fraud Attorneys

There are several situations where it may be necessary to hire medical fraud defense lawyers. In particular, these situations generally arise when there are accusations that your practice is conducting medical business, such as billing Medicare, incorrectly. It’s important to address these accusations quickly to lessen the overall impact on your practice and your ability to continue practicing medicine. Some specific situations where you may need a medical fraud attorney include:

1. Medicare Fraud Charges

Medicare fraud allegations are often levied against physicians and healthcare organizations who are accused of intentionally providing false information or claims to have Medicaid pay for services or care. Examples of Medicare fraud include billing for services that are not medically necessary, billing for services that are not provided to patients, and overusing certain procedures or services, particularly ones that are expensive.

Medicare fraud charges, either formal charges or merely being under investigation for fraud, are serious and will require the expertise of legal counsel to defend these allegations. Experienced lawyers will be aware of the laws that govern healthcare billing, for both federal and state healthcare systems. If you have been accused of fraud or you are under current investigation, some of the laws that may be applied to your case include:

False Claims Act

The False Claims Act is a general law that charges civil liability for any person who knowingly makes a fraudulent claim to the federal government, which is the body that funds healthcare programs like Medicare and Medicaid. Under this act, people who are charged with fraud may be fined up to three times the damages of the claim, as well as penalties up to roughly $20,000 for each false claim. If the False Claims Act is being used for your case, you will need the help of an attorney to defend your case.

Physician Self-Referral Law

The Physician Self-Referral Law, or the Stark Law, prohibits any physician from referring patients to any organization or person related to the physician for healthcare treatment or services that are payable by the federal government through Medicare or Medicaid. In other words, doctors are not allowed to refer patients to organizations that they will gain monetary benefit from, particularly if that benefit is paid by the government.

Violating this law may exclude physicians from participating in offering services for federal healthcare programs. Because the fines for each violation of this law can reach up to $24,000 and because the consequences may prevent physicians from offering services to patients, it’s important to nip self-referral fraud accusations in the bud with help from medical fraud defense attorneys.

2. Medicare Audit

All healthcare services paid for by Medicare or Medicaid are subject to regular auditing by governing bodies. While audits are a common process for federally-paid healthcare services, the auditor may report activity that seems fraudulent, which can kickstart an investigation for fraud or abuse.

In this situation, you will need the help of an experienced attorney to assess your documentation for healthcare services and defend the claims made against you. Swift action during an audit accusation will ensure that your organization’s operations do not halt and you can continue offering services to all patients, including Medicare and Medicaid patients.

3. Up-Coding or Unbundling

Up-coding and unbundling are two other situations where fraud allegations may be made. Up-coding happens when physicians seem to increase payment for services that are ordinarily billed at a lower rate. Unbundling may happen when physicians are accused of seeking individual payments for services associated with procedures performed on the same day (such as charging for anesthesia individually even though two procedures were performed at the same time).

Up-coding and unbundling accusations are sometimes easier to dismiss than other types of fraud or abuse allegations since many of these billing errors can be simple mistakes. Experienced defense lawyers will look at your case and your documentation to help you identify areas where you can make a defense for these billing errors so your charges can be dismissed.

It may be time to hire medical fraud attorneys when you run into situations if you are being investigated or if formal charges have been made against you or your practice. To minimize the consequences to your ability to practice medicine, it’s important to hire experienced fraud defense attorneys who understand the laws the govern healthcare billing practices.