Griffin Durham Tanner & Clarkson have a well-earned reputation for successfully navigating clients through the complexity of healthcare fraud investigations.
This type of fraud is a high-priority area of enforcement for the government, and a large number of people find themselves targeted by investigators each year.
Founded by decorated former federal prosecutors, Griffin Durham Tanner & Clarkson has unique insight into how the government investigates and prosecutes.
Our attorneys have led fraud investigations in some of the largest and most complex cases in the country and have served as:
- United States Attorneys;
- Criminal Chief;
- Criminal Health Care Fraud Coordinators;
- Civil Health Care Fraud Coordinator;
- Affirmative Civil Enforcement Coordinator; and
- Instructors of healthcare fraud for DOJ attorneys
If you are suspected, accused, or indicted on charges of healthcare fraud, you need the knowledge and experience our criminal defense team provides.
One of our healthcare fraud lawyers is standing by to answer any questions you might have. Call our firm at (404) 891-9150 now.
What is healthcare fraud?
This type of fraud involves a wide range of conduct. Many involve how claims are billed to programs and improper relationships between parties in the medical field.
These investigations typically involve allegations of defrauding Medicare, Medicaid, Tricare, workers’ compensation, or private insurance companies.
Healthcare fraud can involve:
- Medical professionals
- Hospital employees
- Testing services
- Rehabilitation or nursing facilities
- Outpatient surgical centers
- Drug stores
- Pharmaceutical companies
Since billions of dollars are lost in health fraud crimes annually, those convicted of perpetrating them can be sentenced to decades behind bars, restitution, fines, and loss of state licenses.
Civil and Criminal Charges: The Threat Is Real
Healthcare fraud is both illegal from a criminal perspective and actionable from a civil perspective.
Criminal courts punish individuals for engaging in illegal activities that are against specific laws and statutes. Civil courts, alternatively, work to provide justice and equity to persons who have been injured by awarding them financial compensation for their injuries.
If you are implicated in healthcare fraud, you may face criminal charges. The state will prosecute your company or organization for its illegal behaviors and sentence them in line with the sentencing guidelines.
When a healthcare organization has engaged in fraud, it may also have civil liability for its actions. This is the element of the action where victims can collect compensation in the civil courts if a settlement outside of court is not possible.
If you have been charged with healthcare fraud, you could be facing both criminal charges and significant costs through any civil case that might develop from the fraud. Knowing what you are facing in terms of healthcare fraud and how to best approach it can be difficult given the many laws and rules that govern the healthcare industry.
Working with an experienced healthcare fraud lawyer will support the best possible outcome in your case.
Have you been accused of one of the following types of healthcare fraud?
A broad spectrum of misconduct is categorized as healthcare fraud. Our accomplished attorneys will customize strategies to protect you from any of the following charges:
- Billing for services not provided or goods never delivered
- Billing for services deemed “medically unnecessary”
- Unlicensed or excluded services where those submitting claims did not follow appropriate enrollment procedures
- “Upcoding” of claims, i.e. inflating the level of service provided to obtain higher reimbursement
- Misrepresenting diagnoses or procedures to maximize payments
- “Unbundling” procedures, i.e. artificially separating procedures that are normally performed and billed as one kind of treatment
- Submitting duplicate claims
- Altering medical records or reports (changing dates, services, patient names)
- Soliciting or receiving kickbacks for goods or services (e.g. receiving referrals, drugs, or money)
If you have been accused of any of these, you face serious consequences. We can help.
Your Opponents Are Formidable
Healthcare fraud investigations are led by sophisticated and well-resourced DOJ units and agencies.
Most investigations will be handled by a local U.S. Attorney’s office. There are U.S. Attorney’s offices across the country, and each district has a designated healthcare fraud coordinator to handle criminal and civil cases. Many offices have specialized prosecutors and teams that focus on fraud prosecutions.
At the DOJ, there are also prosecutors assigned to the Criminal Division, headquartered out of Washington D.C., assigned to various DOJ’s Health Care Fraud Strike Force.
As described by the DOJ, the Strike Force uses advanced data analysis techniques to determine “hot spots” – cities with high levels of billing fraud – combined with traditional investigative techniques.
DOJ has Strike Force operations in Miami, FL; Los Angeles, CA; Detroit, MI; Houston, TX; Brooklyn, NY; the Gulf Coast; Tampa, FL; Orlando, FL; Chicago, IL; Newark, NJ and Philadelphia, PA; Dallas, TX; the Appalachian Region (Tennessee, Alabama, Ohio, Kentucky, Virginia, and West Virginia); and Washington, DC (National Rapid Response Strike Force).
Top-level government agencies:
- Federal Bureau of Investigation (FBI)
- Medicaid Fraud Control Unit (MFCU)
- Department of Justice Health Care Fraud Strike Force
- U.S. DEA (Drug Enforcement Administration)
- U.S. Department of Health and Human Services Inspector General (HHS-OIG)
This is no project for amateurs. It requires one of our capable professional, highly-trained healthcare fraud attorneys.
How Griffin Durham Tanner & Clarkson Can Help
While the federal and state governments have enormous resources, our healthcare fraud defense attorneys have intricate knowledge of how they operate.
We have worked with every agency that investigates these types of fraud claims. We also have established relationships with retired federal agents, including the FBI and Office of Inspector General, U.S. Department of Health and Human Services (HHS-OIG), who we can bring on board to assist our defense team.
We are well-prepared to defend against audits, investigations, grand jury proceedings, state Medicaid Fraud Control Unit (MFCU) teams, False Claims Act (FCA) investigations, Controlled Substances Act diversion investigations, misbranding investigations, and the entire range of fraud or kickback charges.
From the moment you become our client, our healthcare fraud defense attorneys will be proactive. We will undertake our own investigation — examining data, speaking to witnesses, and seeking the advice of experts who may give testimony on your behalf at trial.
We may be able to identify weaknesses in the government’s case upfront and be able to discourage prosecution, cast doubt on your intentional participation in a crime, or at least reduce the exposure you or your company may face.
Medicare Appeals Process
If your claim has been appealed by Medicare, you could run the risk of having to pay for your medical costs and expenses out-of-pocket. Given the substantial sums that medical care can reach in the modern market, having your Medicare claim accepted can make the difference between financial stability for your family, or a future of trying endlessly to catch up to your continually increasing medical costs.
There is a set process to filing a Medicare appeal.
An appeal is made when you disagree with a coverage or payment decision made by Medicare or your Medicare plan. Examples of actions that entitle you to make an appeal with Medicare include:
- A request that you have made for a healthcare supply, service, drug, or item that you think should be covered by Medicare
- A request for the payment of a healthcare supply, service, item, or drug that you have already received
- A request for a change to the amount that you are obligated to pay for a healthcare service, item, drug, or supply
You are also entitled to appeal:
- An at-risk determination that was made under a drug management program that results in limiting your access to coverage from drugs that are frequently abused, like benzodiazepines or opioids
- You can also appeal when Medicare or your plan ceases to provide or pay for all or part of a healthcare service, item, drug, or supply that you think you still need
Your Medicare appeal process and requirements will vary depending on the type of appeal they are filing, which include:
- Appeals in original Medicare
- Appeals in a Medicare prescription drug plan
- Appeals in PACE
- Appeals in a Medicare health plan
- Appeals in a special needs plan
Whatever type of Medicare appeal you are going through, it is essential that you collect evidence in support of your position and claim for appeal. This generally includes asking your doctor, healthcare provider, and even supplier for any information that could be helpful to your case.
Reviewing your plan materials, or contacting your plan directly for details about your rights to appeal, will help you assemble the information that you need to get started. Your membership card will generally have the contact information for your plan, or you can search out your plan’s contact information.
The Medicare Appeals process has five different levels. If you disagree with the decision made on any of the five levels of appeal, you then go to the next level.
Each level of the Medicare appeals process has specific instructions contained in the decision letter on how to move up to the next level of your appeal. All of the instructions included must be followed for your appeal to progress and for you to have the potential of receiving coverage for your issue.
Contact Our Healthcare Fraud Lawyers Today
Griffin Durham Tanner & Clarkson handle healthcare fraud investigations across the country. We will work tirelessly to protect your finances, your freedom, and your reputation from the prosecution’s onslaught.
Reach out to one of our healthcare fraud lawyers to discuss options on your case and to determine the best path to receiving the full coverage you are entitled to.
Call (404) 891-9150 now.