Healthcare Investigation and Audit Defense Chicago

Successful defense of healthcare investigations and provider audits often requires building a team and gathering resources for your specific defense. Whether it is challenging the denial of a claim based on medical necessity, or fighting an extrapolation, expert input is often required to launch a successful defense. Rosenblat Law, a Medicare and Medicaid Audit defense law firm located in Illinois, has the unique ability to put together a team to best challenge a healthcare fraud investigation, defend a recoupment decision, or represent you or your company during a provider audit. This “no ego” approach puts the client first and foremost in all decisions. If you are being investigated or have been charged with a healthcare fraud-related offense contact healthcare fraud criminal defense attorney Michael C. Rosenblat a former prosecutor with the Illinois Medicaid Fraud Control Unit.

Health Care Fraud

What We Do

Rosenblat Law, a Chicago healthcare law firm, 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).

Your Chicago healthcare attorney defense team will be comprised of the individuals needed to confront your specific challenges and will consist of a former Illinois MFCU attorney and, as needed, we will team up with other lawyers often consisting of former federal prosecutors and billing and compliance experts.

We use our experience, insight, and relationships, with the government to aggressively defend our clients and if necessary negotiate a favorable resolution.

Providers receiving notices of overpayment often attempt to submit redeterminations, reconsiderations, and even an appeal to the Administrative Law Judge, without the advice and assistance of counsel. Although healthcare counsel is not required, objective advocacy often results in more favorable provider rulings.

Rosenblat Law works with its healthcare provider clients to provide the representation and services that the healthcare provider wants and needs. Rosenblat Law can provide full representation, or review and advise the physician, dentist, nursing home, or home health agency preparing its own submission. These services can be provided on an hourly rate or as a flat fee service as agreed upon.

Type of Audits

There are several types of audits. An RAC Audit is an audit conducted by a Recovery Audit Contractor, which is 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 and should raise heightened concerns for providers when compared to an 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.

Healthcare Fraud Defense

Typical healthcare fraud cases include Medicare fraud, Medicaid fraud, or kickbacks. Medicare and Medicaid fraud can involve overbilling, billing for services that were not provided, or billing for services that are not reimbursable either because they are fraudulent or because the services fail to qualify for reimbursement. Kickbacks are not only illegal but are viewed as damaging to the integrity of healthcare programs. They create a conflict of interest between where the provider is left to choose between providing the best services for patients and their own financial interest.

Healthcare fraud can also include physicians who prescribe medications for illegitimate reasons, such as the case of physicians accused of operating a “pill mill.”

Examples of Healthcare Fraud

Healthcare fraud alleged to have been committed against Medicare, Medicaid, or a private health insurance company, can include offenses related to the Anti-Kickback Statute; prescribing medications, including controlled substances, without being medically necessary; billing for services never provided; submitting duplicate claims for the same service; billing for non-reimbursable or medically unnecessary services by falsely claiming that the services were reimbursable or medically necessary; using staff or assistants to provide health-related services and then billing as though the services were provided by a physician; and waiving co-pays. These cases often involve an analysis of the relationship between the entities when a kickback allegation is brought, and often an analysis of the CPT Codes, ICD-9 Codes, and even DRG’s when the allegation is one related to the submission of false claims to Medicare, Medicaid, or a private health insurance company.

Trends in Healthcare Fraud Enforcement

Healthcare fraud prosecutions under 18 U.S.C. 1347 have been increasing over the past several years and have increased by almost 10% in the last 10 years. Most of these cases are being investigated by the FBI, followed by Health and Human Services (HHS). The Southern District of Illinois is ranked first in the number of Healthcare Fraud Prosecutions, based on per capita, for 2013. Also in the top 10 were the Northern District of Indiana and the Eastern District of Michigan.

With healthcare fraud estimated to cost the United States over $80 billion a year and increasing, the FBI uses statistical data, obtained from agencies such as the Centers for Medicare and Medicaid Services (CMS), Health and Human Services (HHS), and State Medicaid Agencies, such as the Illinois Department Healthcare and Family Service (HFS), and the State Medicaid Fraud Control Units (MFCU). Law Enforcement techniques have included the use of task forces such as the Healthcare Fraud Prevention and Enforcement Action Team (HEAT), and undercover operations.

Defense of healthcare fraud cases can often include the use of statistical analysis. The government or defense may try to use statistics to support or refute evidence of fraud and may use statistics to support relevant conduct accusations for sentencing purposes.

A Clear Defense Advantage 

Rosenblat Law’s experience in criminal and civil healthcare fraud provides its healthcare provider clients with the insight and experience to avoid or mitigate potential criminal exposure when responding to a notice of overpayment or similar audit.

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. If you are being investigated or audited, contact attorney Mike Rosenblat to discuss your representation. You can contact Rosenblat Law at 847-480-2390, or by emailing Mike at mike@RosenblatLaw.com.

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