Healthcare Fraud

High-stakes investigations where criminal, civil, and administrative risks converge.

Healthcare is among the most heavily policed industries in the country. Physicians, pharmacists, clinic owners, laboratories, home-health agencies, and medical-device and pharmaceutical companies all face scrutiny from a long list of agencies – the Department of Justice, the HHS Office of Inspector General, the FBI, state Medi-Cal fraud units, and others. Allegations commonly involve billing for services not rendered, upcoding, medically unnecessary services, and kickbacks for patient referrals.

What makes these matters especially dangerous is that they often proceed on several tracks at once. A single set of facts can lead to a criminal prosecution, a civil False Claims Act lawsuit – sometimes filed under seal by a whistleblower – and administrative action to suspend payments or exclude a provider from Medicare and Medicaid. Healthcare billing rules are notoriously complex and often ambiguous, and the line between an honest billing error and fraud is frequently far less clear than the government suggests. Effective representation requires managing every one of these fronts together.

IredaleRoth represents healthcare providers and executives at every stage of these matters. For example, we have handled cases concerning allegations of inappropriate billing practices, upcoding, and excessive billing. We also have handled cases concerning allegations of “pill mills” and practices accused of overprescribing. In related contexts, we have also handled matters arising under the False Claims Act and the Anti-Kickback Statute.

Providers facing a healthcare fraud inquiry should consider the following:

• How the inquiry began matters. A subpoena, a civil investigative demand, an audit, a payment suspension, or a visit from agents each signals something different about where the government is headed – and each calls for a different response.

• The civil and criminal sides must be coordinated. Statements made, documents produced, and positions taken in a civil or administrative proceeding can be used in a criminal case, and vice versa.

• The consequences extend beyond fines and prison. Exclusion from federal healthcare programs, loss of licensure, and repayment obligations can end a practice even without a criminal conviction. Protecting the client’s ability to keep working is often a central goal.