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Fraud and Abuse

Fraud and Abuse


Overview

While our day-to-day compliance work focuses on proactive measures clients can take to achieve and maintain compliance, our team also has significant experience in responding to state and federal fraud and abuse investigations when things go wrong.  We have assisted our clients in responding to False Claims Act civil and criminal actions; Medicare and Medicaid billing and coding actions; RAC, MAC, ZPIC, and other payment audits; and FDA and DEA compliance investigations, among others.

Our fraud and abuse team is made up of health care attorneys with regulatory, civil litigation, and white collar criminal defense experience, including attorneys with backgrounds in nursing, clinical research, and accounting and statistics.  We draw from this real-world experience, as well as our experience in dealing with federal and state regulatory agencies, auditors, and investigators, when helping our clients evaluate and respond to fraud and abuse allegations.  While resolving active fraud and abuse allegations is the first priority, we also examine the underlying policies and behaviors and assist our clients in making changes to reduce opportunities for non-compliant practices in the future.

Whether you have been notified that your organization is under investigation or have identified fraud and abuse concerns through internal assessment, engaging the right counsel is essential.  Contact a member of our fraud and abuse team for more information.

Experience

Representative examples of our work in this area include:
 

  • Represented a large hospital system in a criminal fraud and abuse investigation, including resolution of civil and criminal fraud allegations, reduction by millions of dollars of initial overpayment allegations based on a claim-by-claim analysis, and negotiation of CIA and settlement terms
  • Prepared and negotiated self-disclosures on behalf of providers through the OIG, CMS, and state Medicaid agency self-disclosure protocols
  • Represented providers in responding to and settling claims raised in a national qui tam action involving billing for implantable cardiac devices
  • Claims review and negotiation with ZPIC in audit involving E/M and physician supervision coding and billing issues
  • Represented home health agency in appeal of recoupment decision based on ZPIC audit with flawed statistical analysis
  • Conducted Stark and Anti-Kickback analyses of situations involving multiple, complex contracts and lease agreements and negotiation to a conclusion of self-disclosure of identified violations
  • Advised providers regarding appropriate response to compliance hotline calls or complaints
  • Represented providers through the administrative appeals process regarding RAC audits and overpayment determinations
  • Represented providers in responding to Civil Investigative Demands and subpoenas in the context of federal fraud and abuse investigations
  • Represented Medicaid providers challenging recoupment of payments by N.C. Department of Health and Human Services, Division of Medical Assistance (DMA) based on extrapolation
  • Analyzed issues regarding prompt payment discounts for hospital to avoid anti-kickback law and false claims liability
  • Negotiated settlements related to disproportionate share payments, employment of excluded individuals, and specific billing and coding issues
  • Negotiated resolution of over $1 million Medicare and Medicaid overpayment to medical practice with the OIG and NC Medicaid agency, oversaw audit by external consultant, and obtained indemnity for overpayment from the practice's immunology testing vendor
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