Are You Being Investigated for Health Care Fraud? Would You Know it if You Were?

Monday, July 13, 2015
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Shelby Root

Due to the large dollar amounts involved in health care, the great costs of many medical procedures and treatments and the complexity of payment plans, there are those who may attempt to take advantage and defraud the government or others. However, there are also those who just make honest mistakes in billing or whose billing personnel make mistakes; unfortunately, these honest errors may result in a criminal prosecution if not handled correctly.

The Government is Cracking Down on Health Care Fraud.

There are both federal and state initiatives to crack down on health care fraud and this has lead to an increasing number of criminal prosecutions recently. Additionally, "whistleblowers," usually disgruntled former employees, have also caused a number of criminal investigations to be opened based on the False Claims Act or "qui tam" cases that they have filed hoping to obtain a percentage of the monies recovered.

In many instances, the activities of entire fields may be subject to strict scrutiny by federal or state prosecutors. We have recently seen this with targeted case management (TCM) companies, infusion clinics and pain management clinics.

Signs That You May Be the Target of a Criminal Investigation Include:
•    Receiving notice from a patient that the patient was contacted by an investigator;

•    Receipt of a subpoena for records from the Office of the Inspector General (OIG), U.S. Attorney or State Attorney General;

•    Being approached and questioned by a government agent;

•    The arrest of other professionals with whom you do business;

•    The execution of a search warrant for your records;

•    Receiving notice from an employee or former employee that he/she was contacted by an investigator;

•    The seizure of your bank accounts by a government agency;

•    Receipt of a demand letter in a Medicare False Claims Act case;

•    Receipt of a target letter from the U.S. Attorney's Office notifying you that you are a possible target in a criminal investigation; and

•    Receiving a telephone call from a government agent or local law enforcement official to ask you questions.

Medicare Fraud.

When an investigation is being conducted into Medicare fraud, it may include special agents (S/As) of the Office of the Inspector General (OIG), the Federal Bureau of Investigation (FBI), the U.S. Postal Service (USPS), the Food and Drug Administration (FDA), the Drug Enforcement Administration (DEA) or other agencies. Often, state law enforcement authorities will be involved as well.

Medicare fraud carries some extremely harsh penalties, both criminal and civil. These include prison sentences, and significant fines for each false claim that has been filed.

Unfortunately, repeated billing errors of the same type and billing errors that are continued even after audits and educational visits, may be used by the government to prove that there is a criminal intent to defraud the government.

Medicaid Fraud.

Each state administers its own state Medicaid Program. However, state Medicaid programs are funded, in part, with federal funds and are operated pursuant to federal laws, as well as state laws. Therefore, a federal investigation may also include charges of Medicaid fraud. However, for the most part, Medicaid fraud allegations will be investigated by state law enforcement officials.

All states have a state medicaid fraud control unit (MFCU) or similar agency, usually operating under the authority of the state's attorney general or its Medicaid agency. It is usually composed of criminal investigators and prosecuting attorneys. There are often more rules and restrictions governing billing a Medicaid program for services than there are for the federal Medicare Program. Additionally, these regulations and services that may be paid by Medicaid funds vary greatly from state to state.

If the Medicaid provider bills the Medicaid program too many times, bills for services provided by a non-Medicaid provider or makes billing mistakes, then it is at risk of being investigated and charged with Medicaid fraud. Many times the state will conclude that because there were a large number of billing errors of the same type or if they persist after an audit has revealed these errors to the provider, that intentional fraud was committed. Sometimes when there is only one provider of a type of medical service (e.g., oral surgery) in a large geographic area, that person's high amount of billings to the Medicaid program may cause him or her to come under investigation.

The Most Common Types of Problems That May Lead to an Investigation for Medicaid Fraud Are:

•    Billing for services that were not rendered;

•    Billing for services provided by someone not properly licensed or trained to provide that service;

•    Billing for services provided by someone who was not a Medicaid provider;

•    Over-billing or upcoding (billing for more services, more time or a higher level of care than was actually delivered);

•    Billing for items, services, drugs or treatments which the state's Medicaid program that it does not specifically cover;

•    Billing for those who should not receive treatment (dead patients, mentally incapacitated patients); and

•    Billing for drugs, equipment or supplies that were previously provided to the Medicaid provider at no cost.


What are your thoughts on the harsh penalties for Medicare and Medicaid fraud? Please leave any thoughtful comments below.

Contact a Health Care Attorney that is Experienced in the Representation of Medicare and Medicaid Fraud.

The Health Law Firm and its attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicare and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at

About the Authors: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620. Shelby Root is a summer associate at The Health Law Firm. She is a student at Barry University College of Law in Orlando.

KeyWords: Medicare, Medicare fraud, Medicare investigation, fraudulent claims, home health care, Medicare overbilling, defense attorney, defense lawyer, Medicare fraud defense attorney, Medicare termination, Medicare exclusions, qui tam cases, False Claims Act, qui tam, TCMs, targeted case management, whistle blower, False Claims Act defense,Office of the Inspector General, OIG, U.S. Attorney, State Attorney General, Medicare False Claims Act, The Health Law Firm reviews

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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