Defending Clients in National Health Care Fraud Case
Varghese & Associates, P.C. represents two clients, who have been charged as part of the Department of Justice’s 2023 National Health Care Fraud Enforcement Action. The charges, announced by the United States Attorney for the Eastern District of New York, Breon Peace, involve allegations of fraudulent billing schemes related to Medicare and Medicaid.
A licensed occupational therapist, and owner, were arrested and arraigned on June 26, 2023, and subsequently released on a $25,000 bond pending trial. The allegations against our client involve billing Medicare and Medicaid for over $3.9 million in occupational therapy services, of which over $1.6 million was paid. The government contends that many of these services were not eligible for reimbursement, were not provided as billed, or were not provided at all.
The medical assistant and the owner of two pharmacies in Brooklyn, was arrested and arraigned on June 14, 2023, before Chief United States Magistrate Judge Lois Bloom and released on a $500,000 bond pending trial. Our client is charged with conspiracy to defraud in connection with a scheme to pay over $5 million in kickbacks to Medicare and Medicaid beneficiaries in exchange for bringing their prescriptions to her pharmacies. It is alleged that our clients pharmacies received approximately $101 million due to the scheme.
Varghese & Associates, P.C. is focused on providing a robust legal defense for the accused. The firm is reviewing the charges and the evidence presented by the government. A thorough investigation of the facts surrounding the allegations will inform our legal strategy.
The charges against our clients are part of a larger, strategically coordinated, two-week nationwide law enforcement action that resulted in criminal charges against 78 defendants for their alleged participation in healthcare fraud and opioid abuse schemes, involving over $2.5 billion in the alleged fraud.
As legal representatives, Varghese & Associates, P.C. is committed to ensuring our clients receive a fair legal process. We will work diligently to address the charges in court, where the legal system’s procedures will determine the outcome of these cases.
What is the National Health Care Fraud Enforcement Action?
The National Health Care Fraud Enforcement Action is a coordinated effort led by the Department of Justice (DOJ) in the United States, involving multiple federal, state, and local law enforcement agencies. This initiative aims to identify, investigate, and prosecute individuals and entities involved in healthcare fraud schemes nationwide. The action targets fraud against public (e.g., Medicare and Medicaid) and private health insurance programs.
Key aspects of the National Health Care Fraud Enforcement Action include:
Nationwide Coordination
The initiative involves a coordinated effort among various DOJ components, including the Criminal Division’s Fraud Section, U.S. Attorneys’ Offices nationwide, and the Federal Bureau of Investigation (FBI). It also includes collaboration with the Department of Health and Human Services Office of Inspector General (HHS-OIG) and state Medicaid Fraud Control Units (MFCUs).
Focus on Major Fraud Schemes
The enforcement action focuses on significant healthcare fraud schemes, including those involving fraudulent billing practices, medically unnecessary services, kickback schemes, and the prescription of unnecessary medications, including opioids.
Substantial Impact
These enforcement actions often result in the arrest and prosecution of numerous individuals and entities, the seizure of assets obtained through fraudulent means, and the recovery of substantial amounts of money for taxpayer-funded health care programs.
Public Health Protection
Beyond financial recovery, the initiative aims to protect public health by holding accountable those who compromise the integrity of the health care system and patient care through fraudulent activities.
Annual or Periodic Actions
While the DOJ and its partners continuously work to combat healthcare fraud, the National Health Care Fraud Enforcement Action often culminates in a specific period of intensified and publicized enforcement activity, highlighting the government’s ongoing commitment to combating healthcare fraud.
Common Defenses When Charged with Healthcare Fraud
When charged with healthcare fraud, defendants and their legal representatives may employ various defense strategies depending on the case’s specifics, the evidence presented by the prosecution, and the applicable laws. Here are some common defense strategies used in healthcare fraud cases:
Lack of Intent
A fundamental element of fraud is the intent to deceive. A common defense is that the defendant did not intend to commit fraud. This could involve demonstrating that any billing errors were unintentional, resulting from confusion or misunderstanding of complex billing codes and regulations rather than a deliberate attempt to deceive.
Mistake of Fact
This defense argues that the defendant was operating under a mistaken belief that certain practices were legitimate or that certain services were billable under Medicare, Medicaid, or other insurance policies. If a defendant can show that they genuinely believed their actions complied with the law, it could negate the element of intent to defraud.
Insufficient Evidence
The defense may argue that the prosecution has not met its burden of proof to show beyond a reasonable doubt that the defendant committed fraud. This could involve challenging the reliability or sufficiency of the evidence presented by the government.
Entrapment
In rare cases, the defense may claim entrapment, arguing that government agents or others induced the defendant to commit a crime they would not have otherwise committed. However, this defense is difficult to prove and is not commonly successful in healthcare fraud cases.
Reliance on Professional Advice
Defendants might argue that they relied on the advice of legal counsel, accountants, or other professionals regarding how to comply with healthcare laws and billing practices. If defendants can demonstrate that they made a good faith effort to seek and follow professional advice, they might use this to counter allegations of fraudulent intent.
Authorization by Payers
In some instances, defendants may argue that the billing practices in question were explicitly or implicitly authorized by the payers (e.g., Medicare, Medicaid, insurance companies), suggesting that there was no intent to defraud since the defendant believed the practices were approved.
Statute of Limitations
For some charges, there may be a specific time frame within which the government must bring charges. If the prosecution fails to file charges within the statute of limitations, the defense can argue that the case should be dismissed on these grounds.
It’s important to note that the effectiveness of these defenses depends on the specific facts and circumstances of each case. A skilled defense attorney with experience in healthcare law is essential in navigating these complex issues and developing a comprehensive defense strategy tailored to the individual case.
Signs You’re Being Investigated for Healthcare Fraud
Being under investigation for healthcare fraud can be a distressing experience, and it’s often difficult to know for sure if you are being scrutinized. However, several signs may indicate you are under investigation for healthcare fraud. Recognizing these signs early can be crucial for preparing an effective defense strategy. Here are some common indicators:
Unusual Communication from Payers
If you receive an increased number of inquiries, audits, or requests for documentation from Medicare, Medicaid, or private insurers regarding billing practices, it could be a sign of an investigation. Pay particular attention to requests that focus on specific types of claims or services.
Patients Reporting Contact
If your patients inform you that they have been contacted by investigators or insurance representatives asking detailed questions about the services they received (or did not receive) from you, this could indicate an investigation.
Subpoenas or Requests for Information
Receiving a subpoena or a request for information from a government agency, such as the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), or the Department of Justice (DOJ), is a strong indicator of an investigation. These requests can relate to patient records, billing records, or other documentation.
Bank or Billing Service Inquiries
If your bank, billing service, or electronic health records (EHR) provider contacts you about unusual requests they’ve received for your financial or billing information, it could suggest that authorities are investigating your financial transactions.
Interviews with Colleagues or Employees
Learning that federal agents or investigators have interviewed your colleagues, employees, or associates about your practice’s billing practices or services can indicate an ongoing investigation.
Search Warrants
Law enforcement executing a search warrant at your office, home, or storage facility is a clear and direct indication that you are under investigation. A search warrant allows authorities to seize documents, computers, and other evidence related to their investigation.
Suspension of Payments
If Medicare, Medicaid, or other insurers suspend payments to you without a clear, non-investigative reason, it may be due to an ongoing fraud investigation.
Notice from a Professional Association
Sometimes, professional associations or licensing boards may receive notices or inquiries about a member that could be related to an investigation. If your professional association or licensing board contacts you regarding your practices, it could be an indirect sign of an investigation.
Consultation Requests from Legal or Compliance Advisors
If you are advised to consult with legal counsel or a compliance advisor by someone within your professional network without clear reasons, it might be because there are concerns about potential legal issues.
Recognizing these signs early is crucial for proactively addressing the situation. If you suspect you are under investigation for healthcare fraud, immediately consult with a legal professional with experience in healthcare law and fraud defense. An experienced attorney can help you understand your rights, the nature of the investigation, and the best course of action.
How a Healthcare Fraud Defense Attorney Can Help
We understand the complexities and challenges healthcare providers face when they are under investigation or charged with healthcare fraud. Our experienced attorneys are equipped to navigate the intricate legal landscape of healthcare law and are committed to defending the rights and interests of our clients. Here’s how we can help if you find yourself facing allegations of healthcare fraud:
1. Experienced Legal Guidance
Our attorneys possess in-depth knowledge of federal and state healthcare laws, including the False Claims Act, the Anti-Kickback Statute, and the Stark Law. We provide legal guidance tailored to the specifics of your case, helping you understand the charges against you, the potential consequences, and the best legal strategies for defense.
2. Investigation and Analysis
We thoroughly investigate the allegations against you, including a detailed review of billing records, patient records, and other relevant documents. Our team works to uncover and compile evidence that supports your defense, identifies weaknesses in the prosecution’s case, and challenges the allegations of fraud.
3. Negotiation with Prosecutors
Our attorneys have extensive experience negotiating with prosecutors and regulatory agencies. We work to negotiate favorable outcomes for our clients, including the reduction or dismissal of charges when possible. We aim to reach a resolution that minimizes the impact on your professional and personal life.
4. Defense in Court
If your case goes to trial, our skilled litigators will defend you vigorously in court. We develop a strong defense strategy, present compelling evidence, and advocate on your behalf to protect your rights. Our attorneys are committed to achieving your best possible outcome, whether that means a not-guilty verdict, a reduced sentence, or other favorable terms.
5. Compliance and Risk Management
Beyond defending you against current charges, our firm can assist in implementing compliance programs and risk management strategies to prevent future legal issues. We provide guidance on best practices for billing, documentation, and compliance with healthcare laws and regulations, helping you avoid the pitfalls that can lead to allegations of fraud.
6. Professional and Reputational Protection
We understand the importance of your professional reputation and the potential impact of healthcare fraud allegations. Our attorneys work discreetly and efficiently to handle your case, aiming to protect your reputation and your ability to continue practicing in your field.
7. Personalized Support
Facing allegations of healthcare fraud can be overwhelming. Our team provides personalized support throughout the legal process, ensuring you are informed and involved in decision-making at every step. We are committed to addressing your concerns, answering your questions, and providing the reassurance you need during this challenging time.
We are dedicated to defending healthcare providers accused of fraud. Our experience and compassionate and comprehensive approach to legal defense ensure that our clients receive the highest representation. If you face allegations of healthcare fraud, contact us to discuss how we can help protect your rights and future.
Facing Healthcare Fraud Charges? We Can Help.
If you’re facing healthcare fraud allegations, it’s crucial to act swiftly to protect your rights and career. Varghese & Associates, PC has experience in healthcare fraud defense, offering the experience and support you need. From thorough investigations to vigorous court representation, we’re dedicated to achieving your best possible outcome.
Don’t navigate this challenge alone. Contact us now for a consultation and start defending your future today.
