What Do Healthcare Fraud Investigations Involve?

Jan 2, 2019

The National Health Care Anti-Fraud Association estimates that about 3% of the nation’s $2.6 trillion health care budget goes to fraud. That’s equivalent to $68 billion each year.

Health care fraud is a federal crime that comes with stiff punishments. If the fraudulent activity results in a patient’s death, the perpetrator could spend life in prison. 

For many of us, fraud will never be a concern. However, it does happen, and an investigation should ensue. 

Are you concerned about health care fraud investigations? You should be aware of exactly what happens during the course of the investigation. Here we take a look at what the investigation process will involve. 

Health Care Fraud 

First, you should know what health care fraud looks like. Health care fraud is a white-collar crime, meaning it’s a non-violent crime that is used to turn a profit. 

Unfortunately, sometimes this “non-violent” crime results in harm or even death to patients. 

Health care fraud can take on many different forms. Some common schemes include the following: 

  • double billing for the same treatment
  • billing for appointments a patient failed to keep 
  • billing for services patients never received
  • falsifying records to show a patient received services
  • billing for a non-covered service as though it were covered
  • obtaining prescription medications and proceeding to sell them on the black market

If you’re a health care provider, you need to make sure you follow all regulations regarding insurance billing. In 1996, the US Congress implemented the Health Insurance Privacy and Accountability Act (HIPAA). 

This legislation outlines privacy rules concerning health care. It was implemented to reduce waste, fraud, and abuse within the health care industry. 

Review the regulations concerning electronic transmission of healthcare information. Make sure you act in compliance with HIPAA regulations.

If you violate these regulations, you and your practice could come under investigation for fraud. 

Health Care Fraud Investigations 

Health care fraud is a felony with considerable penalties. Federal agencies will need to investigate these cases thoroughly. 

Like other white-collar crimes, these schemes can be difficult to identify. Elaborate systems may be in place to cover up the identity of the perpetrators. 

There are a few ways an investigation could start:

  • an insurance analyst identify suspicious patterns in claims 
  • a patient identifies suspicious billing information and files a complaint 
  • an insider, known as a whistleblower, files a report to the authoritative agency

Once fraud is identified, the investigation will involve numerous agencies. They involve the US Attorney’s Office, the Department of Justice, the Department of Health and Human Services, the IRS, and even the FBI. 

The FBI acts as the federal law enforcement agency in many of these cases. 

Depending on the scope of the case, an investigation may involve government agencies from the federal, state, and local levels. 

These agencies with do a thorough audit of your billing practices. They will look over the information and determine whether or not it seems to be valid. 

If the investigators find any indicators of fraud, they may go back to speak with patients. They may ask patients whether or not they received certain services or treatments. 

They will want to look through electronic transmissions. These can include any records in the possession of the accused individual. 

The investigators will attempt to subpoena everything they can. These investigations are thorough. 

What if My Practice Under Investigation? 

You may receive notice that you or your practice is under investigation. It’s likely the investigative agencies already have enough information to prove fraudulent activity. 

Remember you’re entitled to certain rights under US jurisdiction. If an investigator approaches you asking for an interview, be careful. Anything you say can and will be used against you. 

The investigator may request access to certain documents. They may also request interviews with your employees. 

If this happens, you should contact a lawyer. You have a right to remain silent, but you will need to confront this problem. 

Before you provide any information that will doom you and your practice, speak with your lawyer. 

If the investigators successfully charge you with health care fraud, you could face the following penalties: 

  • criminal prosecution 
  • incarceration for up to 10 years but longer if the fraudulent activity results in injury or death to a patient
  • fines and penalties
  • suspension or loss of your medical license 
  • removal from the Medicare billing program 

If you or your practice has come under investigation, investigators will be ready to prosecute.

It’s possible that there are legitimate billing errors on record. Not all cases are fraudulent.

If you have been accused of a fraudulent health care scheme, you do need to be compliant. These accusations are serious. 

How Can a Lawyer Help?

Health care fraud allegations are serious and shouldn’t be taken lightly. If you receive notice that you or your practice is under investigation, contact a lawyer immediately.

An experienced fraud attorney will ensure you receive your right to due process. Investigations of this manner can be quite aggressive. 

It isn’t uncommon for investigators to acquire evidence illegally. A lawyer will make sure the investigators aren’t violating any of your rights. 

In some cases, evidence could be thrown out. This could make it easier for the attorney to negotiate a favorable plea deal. It could also make it easier for the attorney to have more serious charges dismissed. 

You should never attempt to deal with a serious legal issue on your own. This could be detrimental to your future and the future of your practice. 

Speak with an Experienced Attorney 

If your practice has come under investigation, you may be worried about your future. This is only natural. 

The lawyers at The Grieco Law Center are experienced at handling difficult fraud cases. Our qualified attorneys can practice in several jurisdictions, including Miami and South Florida. 

Protect yourself and your medical practice. Health care fraud investigations will move quickly. Investigators will do anything they can to prosecute you if they suspect fraudulent activity. 

Contact us today to book a consultation.