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Proven Federal Attorneys
Protected Clients in 45+ States

Hamilton Arendsen
Former DOJ
Trial Deputy Chief

Aaron Wiley
Former State &
Federal Prosecutor

S. Amanda Marshall
Former U.S. Attorney

Dr. Nick Oberheiden
Founder

Lynette Byrd
Former Assistant
U.S. Attorney

Medicare Fraud

Medicare Fraud Defense Lawyers

When you are under investigation for phantom billing or up-coding, or accused of billing medically unnecessary services, you do not have time to introduce your lawyer to the world of billing, coding, and medical necessity. You must expect your attorneys to know every nuance and detail of your industry so that the focus in times of crisis can immediately switch to strategic defense.

Medicare fraud constitutes a federal felony and monetary liabilities can be enormous. The possibility of being held accountable for Medicare, Medicaid, Tricare, and other health care fraud, should caution you to invest your time and resources intelligently into a strategic and thoughtful defense plan. Clearly, the last thing you want is the government to brand you as a criminal or to impose civil liability that causes you to lose the business you’ve created. See our track record for yourself and discuss with us how to keep your record clean.

A Medicare Fraud Defense Team You Can Trust

The attorneys of the Oberheiden, P.C. have successfully defended physicians, practice owners, physician owned entities, toxicology laboratories, pharmacies, service management organizations, health care marketing companies, and many others in False Claims Act, qui tam lawsuits, Stark Law, Anti-Kickback, Medicare, Medicaid, Tricare, and DOL investigations. See for yourself; our health care investigation track record is impeccable.

Free Consultation

Oberheiden, P.C. is headquartered in Dallas, Texas, and it assists clients in investigations nationwide. When you call us we will inform you how our Emergency Defense Package will apply to your case. The Emergency Defense Package has been developed by experienced counsel over years and is designed to provide instant relief to targets of investigations. The Emergency Defense Package contains several proven steps to take over control and not be jostled by the government. Call us today and benefit from our experience and industry knowledge.

Contact Oberheiden, P.C. online today.

What Constitutes Medicare Fraud?

Medicare fraud refers to the submission of false or fictitious claims to a governmental health care program. According to government statistics, claims of approximately $ 50 billion per year are considered suspicious and subject to Medicare fraud investigation. Thus, no matter how well you think you have organized your practice and operations, the chances of being audited by Medicare eventually are real, especially if your practice is successful and you submit high volume claims to the Centers for Medicare and Medicaid Services (CMS). In particular, the following statutes form the basis for Medicare investigations:


False Claims Act

Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment to which the health care provider is not entitled, e.g. a laboratory submits claims to Medicare for a higher level of services than actually provided. See, 31 U.S.C. Sect. 3729-3733. For the criminal component of the False Claims Act, see 18 U.S.C. Sect. 287.

Stark Law (Self-Referrals)

Making prohibited referrals for certain designated health services to an entity in which the physician or the physician’s immediate family has an ownership or financial interest or compensation arrangement, e.g. a surgeon refers business to an MRI clinic that his wife owns. See, 42 U.S.C. Sect. 1395nn. For safe harbor exceptions, see 42 C.F.R. Sect. 1001.952.

Anti-Kickback Statute

Knowingly soliciting, paying, and/or accepting any form of remuneration to induce or reward referrals for items or services reimbursed by federal health care programs, e.g. an arrangement that is not covered by regulatory safe harbors and whereby cash or other benefits are offered or exchanged for referrals. See, 42 U.S.C. 1320A-7b(b).

Civil Monetary Penalties Law

Examples for civil monetary penalties to arise are presenting a claim that the claimant knew or should have known is for an item or service not provided as claimed or that is false and fraudulent; presenting a claim that the claimant knew or should have known is for an item or service that is not reimbursable by Medicare; or any violation of the Anti-Kickback Statute.

Civil monetary penalties authorize the government to charge up to $ 50,000 per each false claim plus up to three times the amount claimed for each item or service, or up to three times the amount of remuneration offered, solicited, paid, or received. See, 42 U.S.C. Sect. 1320a-7a


Criminal Fraud Statute

Whoever knowingly or willfully executes or attempts to execute a scheme to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program in connection with the delivery of or payment for health care benefits, items, or services, shall be fined or imprisoned of up to 10 years, or both. See 18 U.S.C. Sect. 1347.

Health care fraud applies not only to health care providers, but instead to “anyone,” including physicians, nurses, practice managers, non-licensed individuals, practice owners, health care businesses, and even institutions.


What are the Penalties?

Medicare fraud is investigated by the Office of Inspector General (OIG), the Department for Health and Human Services (HHS), the Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), Medicaid Fraud Control Units (MFCUs), and State Medicaid Agencies in cooperation with the Health Care Fraud Prevention and Enforcement Action Team (HEAT), the General Services Administration (GSA), and the Centers for Medicare and Medicaid Services (CMS).

If found guilty, targets of investigations may be exposed to recoupment requests, non-payment of future claims, civil fines of up to $ 11,000 per false claim, exclusion from federal health care programs, treble damages, attorney fees, criminal fines, criminal indictment, or incarceration in a federal prison.

Liability does not require a specific intent to violate the law; in fact, the government does not even need to prove actual knowledge of the wrongfulness of the transaction.

Dentists

  • A Los Angeles dentist has been charged for his role in a scheme to defraud Medicare and Medicaid. According to the indictment, the dentist fraudulently billing certain procedures and using his patient’s personal information without their consent. The dentist allegedly would see patients in his office, but then bill Medicare and Medicaid for procedures he did not actually perform. Medicare and Medicaid would then reimburse the dentist for the non-performed procedures. The indictment further alleges that the dentist would use his patient’s private information to continually bill for procedures, even when the patients did not come into his office. As a result of this alleged scheme, the dentist is charged with six counts of health care fraud and two counts of aggravated identity theft.
  • A national dental management company has agreed to a monetary settlement with the United States for its alleged role in submitting false claims to Medicaid for reimbursement. According to the settlement agreement, the dental management company caused the submission of claims to Medicaid based on services provided to low-income children that were either medically unnecessary or were not performed at the standard Medicaid requires. The settlement alleges that the dental management company directed dentists under its control to submit these fraudulent claims in order to increase profit margins. As a result of the settlement, the dental management company will pay $24 million back to the United States and will have to implement a strict compliance program to ensure the issues that gave rise to the settlement do not happen again. Since these allegations were resolved via settlement, there has been no findings of liability against the dental management company.
  • A dentist in Oklahoma has agreed to a monetary settlement with the United States for his alleged role in a scheme to defraud Medicaid. According to the settlement agreement, the dentist was submitting claims to Medicaid for services that were never performed. The dentist is also alleged to have been upcoding certain procedures to make them appear more expensive than they actually were. These allegations against the dentist were investigated by a joint team – including the FBI, OIG and Oklahoma Medicaid Control Unit. As a result of the settlement, the dentist will pay back $5 million to the United States. Since these allegations were resolved via a settlement, there has been no finding of liability against the dentist.
  • A New Hampshire dentist has been indicted on 189 counts of Medicaid fraud. According to the indictment, the dentist, over a five-year period, billed Medicaid for procedures that were medically unnecessary and for services that he has already been paid. The allegations detail how the dentist would perform simple services on his patients, but then use their information to bill Medicaid for expensive procedures, such as root canals and extractions that were never performed. The dentist is also alleged to have developed a scheme where he can be paid double for the same procedure. Each charge the dentist is alleged to have committed carries a possibility of 3 to 7 years in prison.

Oncologists

  • A Michigan oncologist has been indicted for his role in a scheme to defraud Medicare. According to the indictment, the oncologist is accused of intentionally misdiagnosing hundreds of patients with cancer related issues in order to bill Medicare for expensive treatments. The indictment further alleges that the oncologist knew many of his patients did not have cancer but subjected them to chemotherapy and radiation treatments anyway. Many of these healthy patients became gravely sick following their cancer treatments that they did not need. The oncologist allegedly billed Medicare over $150 million in fraudulent claims and pocketed $65 million from this scheme. The oncologist charged with these offenses became a United States citizen in 2009 and could lose his citizenship if found guilty of the allegations.
  • A Washington area oncologist has been indicted for his alleged role in a scheme to defraud Medicare. According to the indictment, the oncologist would bill Medicare for drugs that were never provided to his patients. The oncologist would allegedly write down drug dosage amounts on slips on paper, give the slips of paper to his nurse who would then administer the dosage amount on the paper. The slips of paper would then be destroyed. The oncologist would falsely fill out patient records with a higher drug dosage amount than was actually given to the patient. The indictment alleges the oncologist caused almost $2 million in fraudulent claims to be submitted to Medicare. The illegal reimbursements the oncologist received from the scheme was allegedly transferred to offshore banks in an attempt to hide the money. The oncologist is currently facing 20 counts of healthcare fraud and is facing a significant prison sentence if convicted.
  • A Florida oncologist was convicted by a federal jury for her role in a scheme to defraud Medicare. According to evidence presented at trial, the oncologist was smuggling cancer drugs from unlicensed foreign distributers into the United States and using the drugs to treat her patients. The drugs, since they were unregulated, were not eligible for reimbursement from Medicare, yet the oncologist submitted claims for reimbursement to Medicare anyway. Further evidence showed that the drugs the oncologist used did not contain any active ingredients needed to treat cancer. After the trial, the oncologist was sentenced to 70 months in prison.
  • A New York oncology practice has reached a settlement with the United Sates for its alleged role in a scheme to overbill Medicare. According to the settlement, the oncology practice billed Medicare for cancer related treatment services that were never actually provided. The settlement further alleges that the oncology practice routinely waived Medicare beneficiaries’ copays and instead billed them to Medicare. As a result of the settlement, the oncology practice will pay the United States $5 million. Since these allegations were resolved via a settlement, the oncology practice will not incur any liability.

Dialysis Fraud

  • An employee at a California dialysis center pleaded guilty for her role in a scheme to defraud Medicare. According to the plea agreement, the employee conspired with a California ambulance company to receive kickbacks for the illegal referral of dialysis patients. The dialysis center employee instructed employees at the ambulance company to falsify patient records to indicate that patients needed ambulance transport to her dialysis center, when in fact they did not meet the Medicare requirements for ambulance transport. The employees at the ambulance company submitted the fraudulent transfer bills to Medicare for reimbursement and then would pay the dialysis center employee of portion of the reimbursement funds received. As a result of this scheme, Medicare paid $6 million based on the medically unnecessary ambulance transfers. As part of the plea agreement, the dialysis center employee will pay restitution to Medicare.
  • A major dialysis company has agreed to a settlement with the United States for its alleged role in violating the False Claims Act. According to the settlement agreement, the dialysis company allegedly targeted physicians who treated a large percentage of patients who were eligible for dialysis and would offer them lucrative incentives in exchange for referring their patients for dialysis treatments. The allegations further detail how the dialysis company would protect their referrals by having their referring physicians sign non-compete agreements and not allow the physicians to refer their dialysis patients anywhere other than the dialysis company. To settle these allegations, the dialysis company will pay $350 million back to the United States. Since these allegations were disposed of via a settlement, the dialysis company will not face any criminal liability.
  • An ambulance driver in Los Angeles has pleaded guilty for his role in a scheme to defraud Medicare. According to the plea agreement, the ambulance driver conspired with the owner of a Los Angeles based dialysis center to bill Medicare for services that were medically unnecessary. The plea agreement facts state that the ambulance driver falsified patient reports in order to make them Medicare eligible to receive ambulance transport to a dialysis center. The owner of the dialysis center would then provide dialysis to the patients when many did not need dialysis. Both the ambulance transport and the dialysis treatments were submitted to Medicare for reimbursement. Based on this scheme, Medicare paid $1.3 million for the fraudulent ambulance transfers and dialysis treatments.
  • A Pennsylvania ambulance driver who transported dialysis patients was indicted for his role in a scheme to defraud Medicare. According to the indictment, the ambulance driver falsified medical records of his dialysis patients in order to make them eligible for Medicare covered ambulance transport. The ambulance driver then submitted the cost of the ambulance transport to Medicare for reimbursement. As a result of the scheme, Medicare paid $5.4 million for the medically unnecessary ambulance transports.

Acupuncture Fraud

  • A therapy center owner in California was convicted by a federal jury for his role in defrauding Medicare. According to evidence presented at trial, the therapy center owner enticed patients to his center under the guise of providing free acupuncture treatments. The therapy center owner would perform acupuncture on his patients, but then use their personal information to bill Medicare for occupational therapy services that were never performed. The owner would then falsify patient records to make it look like the therapy services were performed and were medically necessary. As a result of the scheme, Medicare paid over $2 million. As a result of the therapy center owner’s conviction, he was sentenced to 63 months in prison.
  • A chiropractor in Florida who operated numerous wellness centers within the state was indicted for his role in a scheme to defraud TRICARE. According to the indictment, the chiropractor would see patients, but would did not provide any medically necessary services to them, but instead provided acupuncture services – which are not reimbursable by TRICARE. The chiropractor then used the personal information of his patients to bill TRICARE for reimbursable services, such as occupational and physical therapy. The indictment alleged these therapy services were not medically necessary and were never performed. As a result of the scheme, the chiropractor billed over $23 million to TRICARE.
  • Two New York chiropractors were indicted for their alleged roles in a multi-million-dollar healthcare fraud scheme. According to the indictment, the chiropractors billed Medicare and private insurance companies for millions of dollars’ worth of services that were not medically necessary and that were never provided. The chiropractors are alleged to have performed acupuncture services on most of its patients, and then would use the patients identifying information to fabricate records for other services, such as physical therapy and diagnostic testing. Since acupuncture is not reimbursable by Medicare or most other insurance providers, the chiropractors would only submit the bills for the services that were reimbursable. The chiropractors are also alleged to have been operating numerous phony clinics in order not to tip off federal authorities about the vast number of patients they were “treating” at their one clinic. As a result of the scheme, the chiropractors billed Medicare and other insurance companies for more than $80 million.

This is How We Defend Medicare Fraud

When you hire the medicare fraud defense attorneys and former government officials of Oberheiden, P.C., you will notice that we concentrate our defense against False Claims Act, Stark Law, Anti-Kickback violations, and fraud charges by focusing on three core abilities.

Industry Knowledge. We have industry knowledge. Because Medicare fraud often stems from billing and coding errors, intrinsic understanding of CMS protocols is critical. Don’t let misinterpretations of coding policies or missed updates to billing changes expose your practice. You need attorneys that understand billing and coding violations. Our health care fraud defense attorneys have analyzed, reviewed, and defended close to 500,000 billed claims. Similarly, if you are accused of Stark Law violations, you need medicare fraud defense lawyers that understand the safe harbor exceptions to get your case dismissed.

Government Experience. We have government experience. The difference between liability and human error is often a fine line that requires convincing negotiation skills and attention to details. The defense lawyers and former government officials of Oberheiden, P.C. have proven health care and law enforcement experience. Our defense attorneys have extensive knowledge and competence in handling any fraud allegations in the health care industry. See for yourself, and look at our track record.

Civil, not Criminal. We want to keep investigations civil, not criminal. Our attorneys are able to persuade the government that errors, if they exist, were not done intentionally and willfully, but by accident and human error. Doing so is critical because in each fraud investigation the government has two choices: to investigate you to seek recoupments or to prosecute and indict you and seek imprisonment. The law provides for both.

Government Investigation: Civil or Criminal?

One of the predominant questions clients ask us when they call Oberheiden, P.C. for help is to determine if the government investigation against them is civil or criminal; that is, whether the government is seeking monetary remedies or seeking criminal indictments and imprisonment. Health care fraud statutes provide for both, making the issue of civil versus criminal a critical threshold question. About 1,400 individuals are indicted in federal court for health care fraud each year and more than 2,500 individuals are under Medicare criminal investigation.

How do we know? Often times, when we first talk to our new clients and hear their side of the story, we develop a good sense. Years of experience combined with the insight and knowledge of our former government officials allow us to catch certain details and nuances of the investigation that do not strike the general audience as relevant. For example, we pay close attention to how our clients had been notified about the investigation, by which government agency they were contacted, and which government official is in charge of the investigation. The mere involvement of a prosecutor or a federal agency does not mean that the case is a criminal investigation.

Call us today to discuss your case with our medicare fraud attorneys. All initial consultations are free and confidential. We want you to gain relief and to move on with your life. Let us handle your case.

Who Is Investigated?

Health care Fraud exposes providers and business owners alike. Statutes apply to any individual or business that directly or indirectly contracts with and is paid for services by the United States government. Particularly exposed are service arrangements with the government in the following areas:

Industries:

  • Hospitals
  • Home Health Centers
  • Physician Owned Entities
  • Health care Providers (e.g. Physicians)
  • Laboratories (toxicology, biologics)
  • Pharmacies (incl. compound)
  • Medical Device Companies

Recent Examples:

  • Medicare Fraud Strike Force charges 90 individuals
  • Medicare Fraud Strike Force charges 89 individuals
  • Doctor Admits Taking Bribes in Test-Referral Scheme with Lab
  • Owner of Nursing Agency Convicted of Multi-Million Dollar Fraud Scheme
  • Principal in $28.3m Medicare Fraud Scheme Sentenced to 11 Years in Prison


(Published by U.S. Department of Justice at http://www.stopmedicarefraud.gov/newsroom/)

Our Track Record

  • Defense of Medicare laboratory against investigations by the Department of Justice and the U.S. Attorney’s Office for alleged Medicare Fraud
    Result: No civil or criminal liability, case dismissed.
  • Defense of a health care services company against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged False Claims Act and Stark Law violations
    Result: No civil or criminal liability, case dismissed.
  • Defense of Medicare laboratory against investigations by the Department of Health and Human Services and the Office of Inspector General for alleged Health Care Fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of nationally operating health care company against an investigation by the Department of Defense for alleged Tricare fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of health care marketing company against an investigation by the Office of Inspector General for alleged False Claims Act and Medicare violations.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a laboratory against an investigation by various branches of the federal government for alleged fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of physician owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by the Department of Justice for alleged fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged Stark Law violations.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged False Claims Act violations.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by various branches of the federal government for alleged False Claims Act, Stark Law, and Medicare violations.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by the Office of Inspector General for alleged fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by the Department of Defense for alleged Tricare fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of a physician owned entity against an investigation by the Department of Justice for alleged Medicare Fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of physician owned entity against an investigation by the Department of Health and Human Services for alleged Stark Law violations.
    Result: No civil or criminal liability, case dismissed.
  • Defense of health care management organization against an investigation by the Office of Inspector General, the Department of Justice, and the Department of Health and Human Services for alleged Medicare Fraud.
    Result: No civil or criminal liability, case dismissed.
  • Defense of nationally operating laboratory against an investigation by the Office of Inspector General for alleged fraud.
    Result: No civil or criminal liability, case dismissed.

Medicare Appeals Process

With the complexity of the regulations that make up Medicare rules, including its appeals process, there is no substitute for having a lawyer that understands the intricacies of both the law and the Medicare programs. Many healthcare providers, however, believe they can rely on billing professionals or other groups without legal experience to file their Medicare appeals.

The fact of the matter is that filing Medicare appeals without an experienced medicare fraud attorney can lead to costly risks, mistakes, and penalties that could have been avoided with the proper understanding and knowledge of the law.

Medicare appeals take place in the following five steps:

  • Redetermination by a Centers for Medicare & Medicaid Services (CMS) contractor
  • Reconsideration by a qualified independent contractor
  • Hearing before an administrative law judge
  • Review by an appeals council
  • Judicial review in the federal district court

Each step in the Medicare appeals process requires the correct evidence, argument, and punctuality to ensure that errors are not made that affect the rest of the process. Making mistakes in one step of the process may result in significant problems.

Don’t let mistakes in the appeals process create irreparable issues for you later on. At Oberheiden, P.C., our medicare fraud attorneys are experienced with the Medicare appeals process and have a long track record of successfully defending clients facing Medicare fraud charges.

Who Will Handle Your Case

When you hire us, you will not work with paralegals or junior lawyers. Each lawyer in our Healthcare Practice Group has handled at least one hundred (100) matters in the healthcare industry. So, when you call, you can expect a lawyer that immediately connects with your concerns and who brings in a wealth of experience and competence. For example, you need someone like Lynette S. Byrd, a former federal prosecutor in healthcare matters, who recently left the government and who is now sharing the valuable insights she gained as a healthcare prosecutor with our clients.

Dr. Nick Oberheiden

Dr. Nick
OBERHEIDEN

Lynette S. Byrd

Lynette S.
BYRD

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