Healthcare Fraud Investigations: What to Expect
As healthcare expenses continue to rise, federal and state agencies have intensified efforts to identify and prosecute fraudulent activities, launching intensive investigations and filing criminal charges based on highly technical and complex statutes. For healthcare providers facing allegations of fraud, understanding the process of a healthcare fraud investigation is crucial. This article provides an overview of how healthcare fraud cases are commonly initiated, the agencies involved, and the typical stages of an investigation. If you find yourself the subject of a criminal investigation or facing charges of healthcare fraud in California courts, contact The Law Offices of Stanley L. Friedman for advice and representation from a skilled and experienced Los Angeles white-collar criminal defense lawyer.
Initiation of Healthcare Fraud Investigations
Healthcare fraud investigations often begin when irregularities are noted in billing practices or when there are discrepancies in patient records. These can be flagged through routine audits by insurance companies or claims made by Medicare and Medicaid services. Additionally, investigations may start due to reports from whistleblowers who are typically insiders such as employees, patients, or competitors. These whistleblowers might use the Qui Tam provision under the False Claims Act to report fraud with the aim of receiving a portion of any recovered funds as a reward.
Agencies Involved in Healthcare Fraud Investigations
Several federal and state agencies have jurisdiction over healthcare fraud. Chief among them are:
- The Department of Health and Human Services (HHS), specifically the Office of Inspector General (OIG), plays a pivotal role in detecting and investigating fraud within healthcare programs.
- The Federal Bureau of Investigation (FBI) is involved in investigating cases that pertain to both federal and private health insurance programs.
- The Centers for Medicare & Medicaid Services (CMS) also conducts audits and investigations to ensure compliance with healthcare laws.
- State-level Departments of Insurance and Medicaid Fraud Control Units (MFCUs) are crucial in probing allegations of healthcare fraud in state-managed funds.
Stages of a Healthcare Fraud Investigation
Understanding the stages of a healthcare fraud investigation can help providers prepare and respond appropriately. The typical stages include:
1. Investigation and Data Gathering
This initial phase involves the collection of detailed information about alleged fraudulent activities. Agencies use data analysis techniques and audits to detect patterns that suggest fraudulent behavior. This stage is crucial for gathering the evidence needed for a more formal investigation.
2. Interviews and Subpoenas
Once sufficient data is collected, investigators conduct interviews with potentially involved parties, including the provider, staff members, and other relevant entities. Subpoenas for medical records, billing data, and other documents are commonly issued to gather more evidence.
3. Administrative Actions
If investigators find substantial evidence of healthcare fraud, administrative actions such as the suspension of provider payments by Medicare or Medicaid may be taken. These are precautionary measures intended to prevent further losses while the investigation continues.
4. Settlements or Prosecution
The investigation may conclude with a settlement if the evidence supports claims of fraud but the provider opts to settle the matter out of court. However, if a settlement is not reached, the case may move to prosecution, where criminal charges could be filed, and the matter is litigated in court.
Legal Defense in Healthcare Fraud Investigations
Facing a healthcare fraud investigation can be daunting due to the complex nature of the laws and the severe consequences of a potential conviction. The Law Offices of Stanley L. Friedman specializes in defending clients against allegations of healthcare fraud. With a deep understanding of both healthcare law and criminal defense, attorney Stanley L. Friedman provides strategic defense services aimed at protecting the rights of healthcare providers and contesting the allegations made against them.
From challenging the validity of the evidence collected to negotiating with governmental agencies for favorable settlements, The Law Offices of Stanley L. Friedman ensures that every legal avenue is explored to defend clients effectively.
Contact The Law Offices of Stanley L. Friedman for Smart and Effective Defense Against Healthcare Fraud Charges in Los Angeles
Healthcare fraud investigations are intricate and can significantly impact a healthcare provider’s career and reputation. If you or your organization are the subject of a healthcare fraud investigation in Los Angeles, it is essential to seek experienced legal representation immediately. The Law Offices of Stanley L. Friedman is equipped to navigate the complexities of these investigations, offering robust defense strategies to help mitigate potential penalties and safeguard your professional interests. Call 310-598-2000 to discuss your situation today.
