If you’re a healthcare provider facing fraud charges, your license, income, and reputation are at stake. Healthcare fraud cases move fast and are backed by extensive federal resources. Everything you do next matters.
Here are some tips for protecting yourself and responding proactively to your situation.
1. Get clear on the allegations against you
The term “healthcare fraud” can refer to a wide range of actions, including billing errors and allegations of intentional deception. You need to know exactly what conduct is in question. For example, you might be accused of upcoding, billing for services not rendered, or violating the federal Anti-Kickback Statute. Whatever the charges are, make sure you understand the potential consequences in terms of fines and potential jail time. For instance, when fines are assessed per claim, and your billing volume is high, you can expect massive fines.
Identify who’s bringing charges against you. If federal agencies are involved, the case is likely very serious and well-developed. Even if it’s just based on one complaint, you’ll need a good lawyer to fight your charges.
“You don’t need to collect a stack of complaints for a lawsuit to threaten your career,” says a lawyer from SBBL Law. “A single allegation can lead to prosecution and cause you to lose your medical license.”
Next, determine whether your charges are civil or criminal. However, be aware that criminal charges can be filed alongside civil charges. In that case, you’ll face two separate lawsuits.
2. Hire a healthcare fraud defense attorney
When you’re facing healthcare fraud charges, making the wrong move can destroy your future. You need a lawyer who understands both the healthcare system and how the government handles federal prosecutions. Since most healthcare cases are federal crimes and conviction rates exceed 90%, you can’t afford to risk your future by hiring a general lawyer. You need someone who handles cases exactly like yours.
The attorney you choose needs to fully understand CPT codes, reimbursement systems, and compliance protocols. Without this knowledge, a lawyer won’t be able to challenge the government’s story about your actions, and your defense will suffer.
3. Don’t communicate directly with investigators
As a professional with a medical license, you might feel obligated to explain yourself to investigators but this will work against you legally. Every statement you make, no matter how truthful, can be framed as an admission or picked apart for inconsistencies. Many white-collar cases secure indictments based on statements made by the target, even in the absence of demonstrable intent.
Invoke your Fifth Amendment right to remain silent. The prosecution’s only goal is to build a strong case against you and secure a conviction. They aren’t interested in clearing up misconceptions. They will use everything available to support your conviction. You aren’t required to defend yourself. Let your attorney do the talking and manage interactions with investigators.
4. Secure and preserve your records fast
Your documentation is the foundation of your defense, and how you handle it matters. It’s critical to secure your records, but you also need to preserve them without any alteration. Once you’ve been charged, even minor changes to records can be interpreted as obstruction of justice. If you’re convicted of document tampering, federal law allows for penalties of up to 20 years in prison. Even if something doesn’t paint you in a favorable light, it must be preserved unaltered.
All of your billing and patient records, like HER data, claims submissions, emails, and other internal communications, will be scrutinized in detail. At this point, it’s essential to have a lawyer to help organize your evidence and determine how to present it to support your position.
5. Conduct an internal review
You might not even be aware of what happened or how, but you need to understand what happened. Consult your attorney before taking any action, but you might be able to review billing practices and compliance issues in your practice without exposing those findings to investigators. Not every error is fraud, but you need to know what happened in order to create a defense if it was an oversight or just bad habits.
6. Prepare for reputational impact
Even before your case is resolved, the consequences can hit your practice. For example, CMS might suspend Medicare payments while the investigation is happening, and your state’s medical board might initiate disciplinary proceedings that suspend or revoke your medical license.
Protect your future now by securing an attorney
Healthcare fraud charges come with serious risk, but the outcome isn’t predetermined. How your case plays out will be determined by a variety of factors, and it all begins with having a skilled defense attorney.