The Medicare Fraud Investigations Process

The Medicare Fraud Investigations Process

It’s no secret that the Department of Justice has put a high priority on investigating and prosecuting Medicare fraud. Numerous agencies, spearheaded by the Medicare Fraud Strike Force, collaborate to identify, investigate, and prosecute Medicare fraud. But in an effort to combat fraud, countless unsuspecting providers have been put in the crosshairs of the federal government for conduct that is not fraudulent or unintentional. Our Medicare fraud investigators, who all have experience in the State and Federal Government investigating Medicare fraud know what to look for and how to defend against Medicare fraud investigations.

Who Investigates Medicare Fraud?

Just as with any area of federal enforcement, numerous agencies investigate Medicare fraud. An investigation may begin with a MAC audit which is reported to the Office of Inspector General. This is one reason why providers must take MAC audits seriously and aggressively defend them. An investigation may be launched by a local United States Attorney’s office as a result of a tip. The FBI also leverages significant resources investigating healthcare fraud. In addition Medicare has contracted with Uniform Program Integrity Contractors (UPIC) to conduct data analysis on providers who deviate from normal billing behaviors. If a UPIC suspects fraud, the case could be reported to the OIG. We describe each entity below and their role in Medicare fraud investigations.

Health and Human Services Office of Inspector General (HHS OIG)

The Office of Inspector General for the Department of Health and Human Services is one of the key entities investigating healthcare fraud. It has a dedicated team responsible for identifying and responding to fraud in all HHS programs, including Medicare. HHS OIG uses audits, investigations, and inspections to ensure compliance with the laws and to prevent fraud, waste, and abuse.

Medicare Fraud Strike Force

The Medicare Fraud Strike Force is a multi-agency team of federal, state, and local investigators tasked specifically with combating Medicare fraud. Jointly run by the Department of Justice and the Department of Health and Human Services, it uses data analytics to identify suspicious billing patterns and emerging schemes, and to prioritize investigations that keep healthcare dollars where they belong. Founded in 2007, its primary purpose is to detect, prevent, and prosecute health care fraud, especially focusing on areas with the highest instances of deceptive practices. The Strike Force's work is proactive, using advanced data analysis techniques to identify aberrant billing patterns and emerging schemes, followed by real-time investigations.

Department of Justice (DOJ)

The DOJ plays a significant role in the legal side of Medicare fraud investigations. When fraud is suspected, investigators present their findings to the United States Attorney's Office or the DOJ. These bodies then decide whether to pursue charges, both civil and criminal. The DOJ is also involved in prosecuting cases, recovering funds, and negotiating settlements.

Federal Bureau of Investigation (FBI)

The FBI is the principal investigative arm of the DOJ and plays a crucial role in investigating Medicare fraud. The FBI's role in these investigations typically involves complex white-collar crime investigations, including instances of healthcare fraud. The FBI also works closely with other federal and state agencies to uncover and prosecute these crimes.

Medicare Administrative Contractors (MACs)

MACs are private healthcare insurers that have been awarded contracts by the Centers for Medicare and Medicaid Services (CMS) to process Medicare Part A and Part B medical claims from healthcare providers. MACs play a key role in detecting discrepancies or irregularities in Medicare claims submissions, making them a frontline defense against fraudulent claims.

Unified Program Integrity Contractors (UPICs)

UPICs are private entities contracted by the CMS to perform program integrity activities for Medicare and Medicaid. They detect and deter fraud, waste, and abuse within these programs. UPICs conduct audits and investigations and make referrals to the CMS and law enforcement when they identify potential fraud.

These entities all play vital roles in detecting, preventing, and prosecuting Medicare fraud. They collaborate extensively to safeguard the integrity of the Medicare program and protect beneficiaries from fraudulent practices.

The Medicare Fraud Investigation Process

A Medicare fraud investigation, initiated by a Medicare fraud investigator, begins with detection. Irregularities such as billing for services not rendered or unusually high service claims from a single practice can serve as starting points. Once fraud is suspected, investigators utilize statistical data, healthcare records, claim history, and whistleblower information to build a case.

After gathering sufficient evidence, investigators coordinate with legal professionals to determine if prosecution is warranted. This may involve presenting their findings to the United States Attorney’s Office or the Department of Justice, which then decides whether to pursue criminal charges, civil charges, or both.

Steps in the Medicare Fraud Investigations Process

• Opening a case: The source for a Medicare fraud investigation get to the FBI/HHS/DOJ in varying ways. Often it’s from a Medicare contractor that conducted an audit and determined that there are “credible allegations of fraud”. Medicare also employs Uniform Program Integrity Contractors (UPICs) to comb through Medicare data looking for irregularities. Tips can also come from employees, whistleblowers, other providers in the community or a companion False Claims Act case filed against the provider. Once a tip is received that is credible a Medicare fraud investigator can open a case.

• Desk Audit/Statistical Audit: After the case is opened, law enforcement will do a desk audit to review the claims data available. The MEDIC, a contractor responsible for reviewing claims data, will review claims data for potential fraud and produce it to investigators. The investigator will then review the data to determine if the investigation should proceed. The investigator may also look at other Government data to determine if the practice is potentially conducting fraud such as prior audits, prior investigations, prior tips reported by other individuals.

• Covert Investigation: If the investigation progresses law enforcement will begin collecting data covertly to ensure that the provider is not aware of the investigation. This may include reviewing records produced by other entities such as private insurance companies, state medical boards, or other Medicare/Medicaid audits. They may interview former employees or the source of the tip and they may interview other providers in the area. Witnesses interviewed will be encouraged to not disclose the existence of the investigation to the target.

• Overt Investigation: After sufficient data is obtained covertly, the investigators will begin collecting data in an overt fashion. This may include a search warrant, subpoena, or a target letter sent to the provider requesting that they hire counsel and come in and make a statement. If a search warrant is utilized the case would have already been referred to the Department of Justice and United States Attorneys Office for permission to conduct the search. Investigators may then begin contacting current and former employees and current patients.

• Referral to the Department of Justice: When the investigation is nearly complete law enforcement will draft a memo about the case and the allegations and provide it to the Department of Justice or Assistant United States Attorney for review. This memo will climb the chain of command for a decision on whether to open up a grand jury investigation.

• Grand Jury Investigation: If the allegations are sufficiently investigated, prosecutors will take the case to the grand jury. They may take the case to the grand jury to utilize grand jury subpoenas in order to question witnesses or obtain additional documents. They may also utilize a grand jury to seek an indictment for healthcare fraud, wire fraud, RICO, anti-kickback statute violations, or other federal offenses.

How Long Does a Medicare Fraud Investigation Take?

The duration of a Medicare fraud investigation can significantly vary based on the complexity of the case, the amount of evidence involved, and the resources available to the investigating team. Generally, investigations can take several months to multiple years to complete.

Examples of Medicare Fraud/ Medicare Fraud “Red Flags”

Medicare fraud encompasses various practices. One common example is billing for services not rendered, where healthcare providers bill Medicare for procedures or tests that were never conducted. Other instances include:

1. Upcoding: Providers may bill for a more expensive service than what was actually provided to the patient, such as coding a simple procedure as a more complex one to increase reimbursement.

2. Unbundling: Unbundling is when providers bill each step of a procedure as if it were a separate procedure, which can lead to higher payments from Medicare.

3. Duplicate Billing: This type of fraud occurs when providers submit multiple claims for the same service performed on a patient.

4. Phantom Billing: In this case, providers bill for unnecessary procedures, tests, or services that are not medically necessary for the patient's condition.

5. Kickbacks: This fraud involves providers receiving financial benefits, gifts, or compensation in exchange for referring patients to other healthcare providers or for prescribing certain drugs.

6. Identity Theft: Fraudsters may steal patient's Medicare information and use it to bill for services or supplies that were not provided.

7. Improper Relationships with Pharmaceutical Companies: Some providers might receive incentives from pharmaceutical companies for prescribing specific drugs, leading to overutilization.

8. Falsifying Patients' Diagnoses: Providers might exaggerate or make up patient diagnoses to justify unnecessary tests, surgeries, or other medical procedures.

9. Overprescribing Medication: In some cases, providers prescribe more medication than necessary, bill Medicare for the extra amount, and then sell the surplus.

CCG Healthcare: Your Defender Against Medicare Fraud Investigations

At CCG Healthcare, we have the experience, skill, and strategic insight to effectively navigate through Medicare fraud investigations. Our team comprises seasoned Medicare fraud defense investigators, including former federal and state officials, renowned for securing more high-profile Medicare fraud acquittals than any firm in the country.

We delve deep into the details, using our thorough understanding of the Medicare fraud investigation process and the factors that influence the investigation duration. We are uniquely positioned to identify and articulate potential defenses and to minimize the potential consequences for your practice.

We understand the stress and potential impact of a Medicare fraud investigation on your healthcare practice. Our team not only possesses extensive knowledge of who investigates Medicare fraud but also the tactics these investigators employ, thereby positioning us uniquely to predict and counter potential allegations.

Leveraging our former Medicare fraud investigators, we can provide invaluable insights into billing for services not rendered and other examples of healthcare fraud. This experience helps us identify Medicare fraud red flags early on, allowing us to proactively address concerns and avert further scrutiny.

Trust us to secure your practice's future. We understand the gravity of these situations, the fear of losing hard-earned reputation, and the anxiety about potential financial or legal penalties. Our role is not limited to defense alone; we aim to stand by your side, providing guidance, support, and reassurance during this challenging time.

With CCG Healthcare, you can be confident that you have a committed partner who knows the system from inside out. We have turned the tables in countless high-stakes cases, giving our clients the upper hand in their battles against fraud allegations.

The prospect of facing a Medicare fraud investigation can be overwhelming, but remember, you're not alone. Investigations can take months or even years, and early legal representation is crucial to building a strong defense.

Why You Should Consult with CCG Healthcare

If your practice is facing a Medicare fraud investigation, it's time to get serious about your defense strategy. At CCG Healthcare, we can commence a Medicare fraud defense investigation promptly, increasing your chances of a favorable outcome.

Our unparalleled track record of high-profile Medicare fraud acquittals speaks volumes about our expertise and commitment. It's not just about defending you in the courtroom; we're here to guide you through every step of this process, helping you understand the nuances and ensuring that your rights are always protected.

Take action today.

Reach out to CCG Healthcare and let us put our extensive experience, vast resources, and relentless commitment to work for you. We're ready to stand with you, providing the robust defense you deserve and the peace of mind you need in these trying times. Our first priority is always you - your practice, your reputation, and your future. It's a battle we're prepared to fight, and it's a battle we're equipped to win.