Health Care Fraud

The United States government focuses on monitoring various regions of the country for health care fraud. Chicago is one of those regions and is monitored by a Medicare Fraud Strike Force.

The U.S. Department of Justice operates a healthcare fraud strike force in Chicago, which has one of the highest instances of fraud indictments in the nation, and in 2016, the Department of Justice released a statement that revealed a nationwide arrest of more than 300 individuals for health care fraud. Individual healthcare providers were at the center of 80 of those investigations—the other cases centered around health care entities and businesses. The Medicare Fraud Strike Force recovered more than $900 million in fraudulently paid out claims.

Any health care professional like a doctor, pharmacist, pain management specialist, nurse, chiropractor, or more could see their career at stake if they receive a grand jury subpoena or are under investigation for healthcare fraud. Not only could they face losing thousands of dollars in fees, loss of personal and business property, along with prison time, but they could also lose their license and entire career.

Health care fraud cases can be very complex and require in-depth knowledge and experience with health care law. Federal and State law enforcement use task forces, undercover operations, data analysis, and other means to find and uncover fraudulent activities.

If you are a health care provider in Chicagoland and are facing false claims, you need to contact a health care fraud attorney from Rosenblat Law. We have experience defending medical professionals against health care fraud charges by fighting for non-guilty verdicts, pretrial dismissals, and plea agreements. Our expertise allows us to obtain desired results for professionals facing health care fraud with carriers like Medicaid, Medicare, and TriCare.

What is Healthcare Fraud?

Broadly defined as making false claims to a healthcare program, for example, this can include submitting a false bill for Medicaid services that were not provided. Factors that are involved can include:

• Defrauding a healthcare program
• Devising a fraudulent scheme
• Executing a fraudulent scheme

So, what does this mean? False claims can mean anything from billing for services that were never carried out, billing for unnecessary medical procedures or items, improperly using CPT codes, and upcoding.

Given the complex nature of Chicago health care fraud, it’s essential to speak with a lawyer focusing in this practice area instead of a general criminal defense lawyer. Your lawyer will work with you to weaken the government’s case against you and to build a strong defense using expert statements, regulations, case law, statistics, and more to hold the government accountable to their burden of guilt – beyond a reasonable doubt. We work to ensure that you are not charged or convicted over a difference in opinion concerning:

• Urinalysis testing guidelines
• Opioid prescribing guidelines
• Back injection guidelines
• Upcoding
• Improper maintenance of medical records
• Unbundling
• Improper CPT Codes

How is Healthcare Fraud Investigated?

When health care providers are audited, they are investigated by a different state, federal, and local agencies, including the Federal Bureau of Investigation, the Drug Enforcement Administration, and the Human Services Office of Inspector General.

In fact, there are quite a few task forces that collaborate to identify any kind of healthcare fraud.

At Rosenblat Law, our healthcare fraud defense practice has years of experience defending clients who have been charged with fraud. Each client’s case is unique to their circumstances which requires a tailored solution.

Healthcare Investigations and Audit Defense in Chicago

Successfully defending healthcare investigations, health care fraud, and provider audits require experienced law professionals. Successfully defending allegations of fraud or overbilling requires expert input to challenge the denial of a claim based on lack of medical necessity or fighting an extrapolation.

Rosenblat Law, a Medicare and Medicaid Audit defense law firm located in Illinois, has the unique ability to put together the best challenges to a health care fraud investigation, defend a recoupment decision, or represent you or your company during a provider audit.

Our “no ego” approach puts the client’s needs at the forefront of all our decisions. If you are being investigated or have been charged with a health care fraud-related offense, contact health care fraud criminal defense attorney Michael C. Rosenblat. A former prosecutor with the Illinois Medicaid Fraud Control Unit.

What We Do

Rosenblat Law is a Chicago healthcare law firm that represents providers in RAC Audits (Recovery Audit Contractors), ZPIC Audits (Zone Program Integrity Contractors), private payor audits (Blue Cross Blue Shield, Aetna, etc.), Medicaid OIG Audits (Illinois Department of Healthcare and Family Services/Office of Inspector General), and MFCU Audits and Investigations (Medicaid Fraud Control Unit).

Our Chicago health care fraud defense team will be composed of Medicare and Medicaid fraud lawyers who are ready to confront your specific challenges. Your defense team will consist of a former Illinois MFCU prosecutor who will collaborate with other former prosecutors, billing, and compliance experts as needed.

We use our experience, insight, and relationships with the government to defend our clients aggressively and negotiate a favorable resolution when necessary. Our lawyers defend clients from across the health care industry, including:

• Individual doctors, nurses, and pharmacists
• Durable Medical Equipment (DME) Companies
• Home health care companies
• Dentists and Dental Clinics

Rosenblat Law works with healthcare providers to provide the representation and services that they need.

Rosenblat Law can provide complete representation to physicians, dentists, nursing homes, or home healthcare agencies. These services can be provided at an hourly rate or as a flat fee.

Illinois Healthcare Fraud Enforcement

In Illinois, healthcare fraud is indicated by the Office of the Illinois Attorney General, the United States Attorney’s Offices, and the State’s Attorneys.

The United States Attorney and Illinois Attorney General often work with whistleblowers to curb fraudulent activities.  The Illinois False Claims Act allows citizens to enact a qui tam action that metes out civil penalties and allows them to receive a percentage of the recovered finances.

According to the Illinois False Claims Act, §740 ILCS175/3(a)(1), someone is liable for making a false claim if they do any of the following:

• Intentionally filing a false claim to be paid
• Intentionally create a false record to uphold a false claim
• Conspire to violate the False Claims Act

Examples of Chicago Healthcare Fraud

Typical healthcare fraud cases include Medicare, Medicaid, or private insurance fraud. Health care fraud often involves billing for services not provided, billing beyond the actual cost of services, or billing for services that were not medically necessary.

Alleged healthcare fraud offenders could be:

• Clinics
• Health insurers
• Hospitals and their systems
• Home healthcare companies
• Physicians and Dentists
• Medical institutions
• Medical facilities
• Nurses
• Pharmacists

Healthcare fraud that conspires against Medicaid, Medicare, or any private insurance provider may include the following common offenses:

• Violating the Anti-Kickback Statute
• Billing for medically unnecessary services
• Billing for services never provided
• Billing for services provided by staff or assistants as if a physician provided the services
• Prescribing medications, including controlled substances without medical necessity
• Submitting duplicate claims for the same service
• Waiving co-pays

Healthcare fraud prosecutions have grown exponentially over the past several years. Healthcare fraud is estimated to cost the United States over $80 billion a year—a figure that is ever-growing.

Types of Audits

There are several types of health care fraud audits.

A RAC Audit is an audit conducted by a Recovery Audit Contractor, a private company acting on behalf of the Center for Medicare and Medicaid Services. RAC’s are paid on a contingent fee basis and are thus incentivized to find and recover alleged overpayments.

ZPIC Audits: Zone Program Integrity Contractors are tasked to identify fraud. They raise heightened concerns for providers compared to a RAC Audit.

The Medicare Appeals process has five levels of appeal:

1. Redetermination
2. Reconsideration, conducted by a Qualified Independent Contractor (QIC)
3. Hearing before an Administrative Law Judge
4. Hearing before the Medicare Appeals Council
5. Judicial review

Rosenblat Law provides experienced legal defense in Chicago, Illinois, and the surrounding areas for healthcare providers, businesses, and entities investigated for healthcare fraud.

Experience as a former healthcare prosecutor and expertise as a defense attorney provides a unique perspective on how to handle these types of cases best.

If you need an experienced health care fraud attorney in Chicago or throughout Illinois, contact Rosenblat Law today for a consultation to discuss your options.

Call the Health Care Fraud Attorneys at Rosenblat Law Today

Being investigated for Medicaid, Medicare, or other health care fraud claims can be very serious. Contact Rosenblat Law right away so we can help you defend your reputation, career, and future.

Our experience in criminal and civil health care fraud provides our healthcare provider clients with the insight and expertise to avoid or mitigate potential criminal or civil exposure.

Rosenblat Law’s attorneys will use their experience, knowledge, relationships, and skills to protect you and your business. These common defenses could include insufficient evidence or a lack of criminal intent.

If you are being investigated or audited, contact attorney Mike Rosenblat to discuss your representation. Mike Rosenblat has been practicing healthcare law for over twenty years — since he was an Assistant Attorney General assigned to the Medicare Fraud Control Unit. You can contact Rosenblat Law at (224) 331-1611 or by emailing Mike at mike@RosenblatLaw.com.

Rosenblat Law has offices located in Northbrook and Chicago, Illinois.