Healthcare providers want to give their Medicaid patients the best care possible. Providing that care requires listening, observing, diagnosing, recommending, and prescribing. Each step comes with a list of other responsibilities, such as ordering tests, making referrals, reporting every detail of the patient’s care, and filing all information with Medicaid for reimbursement.
Most providers take great care to remain in compliance with Medicaid’s many complicated rules, regulations, and record-keeping requirements and still, some find themselves unexpectedly under investigation for Medicaid fraud. As the impact of the COVID-19 restrictions begins to wane on investigators and the Medicaid Fraud Control Unit (“MFCU”), providers are seeing ever-increasing numbers of on-site inspections, subpoenas, requests for information, and interview requests. If you are a healthcare provider facing a fraud investigation, protect your rights, practice, provider privileges, and freedom by partnering with a Georgia healthcare fraud lawyer from Griffin Durham Tanner & Clarkson LLC.
Understanding Medicaid fraud
Medicaid is a government healthcare program providing benefits to eligible children, pregnant women, low-income adults, older adults, and disabled individuals. The program has joint funding by state and federal governments.
The Georgia Department of Law has established a specific Medicaid Fraud Division to combat and prevent Medicaid fraud. Since 2016, this division has recovered over $85 million through enforcement efforts. The government takes Medicaid fraud seriously.
“Fraud” often makes us think of grand schemes or conspiracies, but not all acts are so elaborate or even purposeful. Providers can come under investigation even if the issues investigators are not obvious cut.
Types of Medicaid fraud
One way to avoid fraud is through awareness and understanding what some of the more common forms of Medicaid fraud look like. These can include the following:
- Billing for unnecessary services
- Billing for services not provided
- “Unbundling,” or using multiple, individual billing codes for services that fall under a single “global” billing code
- “Upcoding,” also known as billing for services at a “higher level of complexity” than provided
- Card sharing by treating and seeking reimbursement for a person other than the designated beneficiary
- Providing kickbacks by compensating patients or referring providers
- Medically unnecessary services or prescriptions
- Billing for an ineligible Medicaid beneficiary
Fraud Intent Requirements
These acts only count as fraud if they are committed intentionally or knowingly. Many fraud schemes that prosecutors elect to charge as a criminal violation involve clear instances where an individual knew what they were doing was wrong. One example is billing for treating a patient when the provider never actually saw the patient. But many other “fraud” investigations involve much less clear issues. While private providers own their practices, they still have office professionals running the office and handling billing. An intentionally dishonest worker could perpetuate fraud without the provider’s awareness, or a careless worker’s mistakes could prompt an investigation.
Responding to an investigation
A recent article published on the National Library of Medicine (NLM) site offers recommendations for healthcare providers to protect themselves from committing fraud, waste, and abuse. Providers must take care to understand fraud and abuse laws. A Georgia healthcare fraud lawyer can help and provide resources for developing compliance plans in the practice.
If you find yourself or your practice in receipt of a subpoena, on-site inspection, or interview request from the Medicaid Fraud Control Unit, you should contact us for assistance. We can help advise as to immediate responses, contact the prosecutors, and identify strategies to address the prosecutor’s concerns. Our healthcare fraud defense attorneys include former federal healthcare fraud coordinators and Medicaid Assistant Attorney Generals, who have significant experience with Georgia’s Medicaid Fraud Control Unit and assisted our clients in addressing fraud investigations, resulting in no charges filed and the cases closed by the prosecutors.
Come to us for the legal protection you need
Can “fraud” be unintentional? It can, and the fact that something done unknowingly and without ill intent can bring costly civil, criminal, and professional consequences is frightening. Medicaid is complicated, requiring careful attention to various rules, standards, regulations, and laws on both state and federal levels. It isn’t hard for busy healthcare providers to overlook a detail or mis-code a service.
The stakes are high in healthcare fraud cases, and we are ready to provide a powerful, convincing defense. Our team has comprehensive knowledge of state and federal Medicaid laws, extensive experience–and success–defending against Department of Justice (DOJ) prosecutions, and the resources necessary to design a strategy that delivers results.
If you face fraud charges, contact a Georgia healthcare fraud attorney from Griffin Durham Tanner & Clarkson LLC immediately. Atlanta providers can call (404) 891-9150, and those in Savannah call (912) 867-9140. You can also send an electronic message explaining your questions, concerns, and needs.