Federal Health Care Fraud Defense

Health care fraud investigations often start with a request for documents. Other first signs can include an audit, suspended Medicare or Medicaid payments, a subpoena, a civil investigative demand, or contact from FBI or Department of Health and Human Services Office of Inspector General agents.

Investigators have often spent months on claims data by then, and many cases begin as a sealed False Claims Act whistleblower suit, so a civil case and a criminal investigation can move at the same time.

Bedi & Singer represents physicians, nurse practitioners, pharmacists, practice owners, home health and medical equipment operators, executives, and people responsible for health care management and business operations in federal health care fraud matters nationwide, before and after charges are filed.

Federal health care fraud, 18 U.S.C. § 1347, makes it a crime to knowingly and willfully execute a scheme to defraud any health care benefit program, including Medicare, Medicaid, TRICARE, and private insurers. It is often charged with wire fraud, conspiracy, false statements relating to health care matters (18 U.S.C. § 1035), and Anti-Kickback Statute violations.

The allegations usually concern billing:

• Services not provided or not medically necessary
• Upcoding, unbundling, or misstated dates of service
• False homebound or eligibility certifications
• Payments for patient referrals
• Prescriptions not dispensed or written outside the usual course of practice
• Routine waivers of copayments and deductibles

A coding error, a documentation gap, or a reasonable reading of an unclear rule is not a crime; the government must prove the person acted knowingly and willfully.

What to produce, who speaks with investigators, and how to answer a payer audit can shape the case that follows. Someone may need counsel after:

• A grand jury or administrative subpoena for patient and billing records
• A civil investigative demand or suspended payments
• Contact from FBI or HHS-OIG agents
• A search of a practice, pharmacy, or office
• Interviews of employees or billing staff

Early counsel can help determine whether the matter is civil, criminal, or both, manage records production, prepare for or decline interviews, and, when the facts support it, give the government information that may change how it views the case.

The government typically relies on claims data, a statistical sample of patient files, and a cooperating insider. The defense tests each one:

• Were the billing rules at issue clear at the time?
• Do the sampled files support the government’s loss figures?
• Were services medically necessary in the treating clinician’s judgment?
• Did the client know about billing practices set by others?
• Do payments to marketers or referral sources fit a statutory exception or regulatory safe harbor?
• Do cooperating witnesses have reasons to shade their accounts?

This often calls for independent coding, billing, and clinical experts. Loss amount drives sentencing under the federal guidelines, so the numbers matter at every stage.

Jonathan Bedi and Dena Singer work on Bedi & Singer’s cases together. Clients are told not only what the lawyers are doing but why, including how the case affects patients, staff, payers, and licensing.

Many health care fraud matters end before trial, but Bedi & Singer tests the government’s data, experts, and witnesses from the beginning the way a jury would see them. Both partners have tried many bench and jury trials, and Bedi & Singer has substantial experience defending complex white-collar matters involving financial fraud, wire fraud, and conspiracy.