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Successful Challenge to Healthcare Fraud DOJ Prosecution

March 27, 2020
By Mohamed H. Nabulsi, Damian P. Conforti and Ronen Yair

We are happy to report that we recently delivered excellent news to one of our physician-clients. In 2019, the United States Department of Justice charged this client with insurance fraud in connection with the submission of claims to Medicare/Medicaid for services rendered by the client’s nurse practitioners, but billed under the client as the rendering provider. After months of vigorously defending our client, the DOJ dismissed the charges against him, pre-indictment, without the need for a trial. In mounting this defense, we utilized a team approach, in which members of our healthcare practice group, in collaboration with members of our white collar/government enforcement group, reviewed and analyzed hundreds of medical records and corresponding claims, analyzed our client’s billing practices under relevant documentation, coding and billing laws/regulations and guidelines, and presented reports of our findings, as well as exculpatory evidence, to the government to demonstrate that its case was not provable beyond a reasonable doubt. Shortly thereafter, the government voluntarily dismissed its case.

While billing errors usually result in civil recoupment actions by payors, as demonstrated by our client’s case above, they also could result in criminal prosecution. The foregoing victory demonstrates that federal healthcare-related charges may be successfully challenged with effective lawyering; however, healthcare providers should focus their efforts and resources on preventing such charges in the first place. Preventative measures should include periodic self-audits to identify errors and confirm adherence to applicable laws, regulations and guidance, etc. Unless you conduct period self-audits to confirm the propriety of your documentation, coding and billing practices, you may be unknowingly submitting false claims to governmental/non-governmental payors, which could expose you to criminal prosecution, civil liability and/or administrative sanctions. In our client’s case, one of the biggest weaknesses was a documentation/billing issue that arose from an undetected, inadvertent, technology-generated error that resulted in the relevant claims being billed under the client irrespective of who actually rendered the service.

Please contact us to discuss what you can do to help avoid being subjected to legal scrutiny as a result of billing errors.

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