PA 04 · Practice area
Healthcare fraud
Billing audits, HHS-OIG and FBI inquiries, kickback and False Claims Act exposure. For physicians and owners, the license is on the line along with the case.
Healthcare matters run on several tracks at once: a criminal inquiry, a civil False Claims Act case, payer audits, exclusion from federal programs, and the licensing board. We represent physicians, practice owners, billing companies and clinical staff, and we keep those tracks pointed in the same direction.
Usually for
Physicians, dentists, pharmacists, practice owners, billing and coding staff, and healthcare company leaders.
You are reading: Is this you?
Is this you?
It may be time to call if…
- A payer audit, prepayment review or records request has escalated.
- Your practice received a civil investigative demand or an HHS-OIG subpoena.
- Agents are interviewing staff, former employees or patients.
- A former employee left on bad terms and may have filed a whistleblower case.
- Referral or marketing arrangements are being questioned.
Where this sits in a federal case
Where this work usually happens.
Marked on the rail: investigation; grand jury; plea discussions; and sentencing. Select any stage to read what it means in our plain-language guide.
What we do
Five things, in roughly this order.
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1
Map every track
Criminal, civil, payer and licensing exposure are listed on one page, with the deadline and the decision-maker for each.
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2
Bring in coding experts under privilege
Independent coders review a sample of claims, so we know what the records support before anyone else draws conclusions.
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3
Review referral arrangements
Marketing, medical director and referral agreements are checked against the kickback and self-referral rules that apply.
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4
Protect staff and patients
Employees are told their rights and prepared for interviews. Patient care continues without disruption wherever possible.
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5
Resolve the right way
Many billing matters belong in a civil or administrative process. When they do, we work to keep them there.
This week
What to do, and what to leave alone.
Do
- Preserve billing data, audit trails and email as they are.
- Keep treating patients and documenting care normally.
- Tell your malpractice and business insurers as your policy requires.
Avoid
- Changing old charts or adding late entries.
- Questioning staff about what they told investigators.
- Paying back money to a payer without advice on what that signals.
General information, not legal advice for your situation. Speak with a lawyer before acting.
Terms, in plain words
The words you will hear.
- Qui tam case
- A civil lawsuit filed by a whistleblower on the government's behalf. It is usually kept sealed at first, so the practice may not know it exists.
- Exclusion
- Being barred from billing Medicare, Medicaid and other federal programs. It can follow some convictions and some civil settlements.
A physician-owned clinic faces a billing inquiry
Modest result
- Situation
- Investigators questioned the clinic's billing for one high-volume procedure over four years.
- What we did
- Our coding expert's sample review showed most claims were supported, and we presented the findings with a corrected billing policy.
- How it ended
- The matter resolved as a civil repayment for the unsupported claims. No criminal charges were filed.
An illustration with details changed and no names, courts or cases. Every matter turns on its own facts; past results do not guarantee any outcome. See all example matters, including ones that went against us.
Questions
What people ask us first.
Does a billing audit mean a criminal case is coming?
Not usually. Most audits stay administrative. But some escalate, and what a practice says and sends during an audit can matter later, so it is worth getting advice early.
What is a whistleblower or qui tam case?
A private person, often a former employee, files a civil case on the government's behalf and may share in any recovery. The case is sealed while the government investigates.
Will I lose my license?
It depends on the outcome and your state's rules. Licensing consequences are one of the first things we plan for, not an afterthought.
Confidential consultation
Talk to us about healthcare fraud.
A short, confidential call is often enough to learn where you stand and what to leave alone this week. Do not send details through the form; we will cover them by phone.
Please do not send case details through any website form or by email. We cover them by phone or in person, under privilege.
Consultation line: 7 days, 7:00 a.m. to 10:00 p.m. If a search or an arrest is happening now, call at any hour.