A physician may face accusations of health care fraud for a variety of reasons. If you learn you are under investigation, consulting a qualified attorney as soon as possible can keep you from making mistakes that could undermine your defense.
Do not make the mistake of thinking a current lack of criminal charges means you can afford to take this lightly. Even if you ultimately avoid the worst-case scenario of conviction, an investigation can disrupt your practice and damage your reputation.
Health care fraud
A health care provider may face investigation based on accusations of defrauding a private insurer, Medicare or the state-administered Medicaid program. While the processes for investigating and prosecuting these three types of fraud vary in their specifics, they also have a lot in common.
The reasons for the investigation
Some common reasons authorities may audit physicians include employees or patients giving information to law enforcement and suspect billing patterns. Practitioners in certain fields, such as pain management, may receive especially strict scrutiny.
Mistakes can land you in trouble
Oftentimes, accusations of fraudulent billing practices arise due to an erroneous billing practice that never gets corrected. For example, an employee consistently uses the wrong code and no one notices, so the employee continues doing so. As a physician, you may be held responsible for failing to correctly train and supervise your employees. For this reason, many physicians develop a compliance protocol designed to catch and correct possible paperwork mistakes.
How to know you are under investigation
An investigation may begin officially, with a formal notice of a subpoena of your records. You may also learn you are being investigated if you find out law enforcement agents have been interviewing your employees or patients. Investigators may also approach you or call you on the phone seeking information. This last approach may seem informal, but resist the temptation to believe everything will go away if you just clear things up. Avoid speaking with investigators without consulting your attorney first, as you do not want to inadvertently provide ammunition against yourself.