Healthcare & Medicare Fraud Defense Attorney
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Tackling complex cases & seeing them through
When you are under investigation for phantom billing or up-coding, or accused of billing medically unnecessary services, you need an attorney who has witnessed similar cases.
Commitment to help with difficult cases
Invest your time and resources intelligently into a strategic and thoughtful defense plan with Michael J. Khouri, an attorney who has decades of experience.
Eliminate Your Stress
Healthcare & Medicare fraud defense can be a stressful process but it does not have to be if you are represented correctly. Gain peace of mind knowing that you are in good hands.
Medicare Fraud Defense Lawyers
Prosecuting Medicare Fraud is a top priority of the government. Each US Attorney’s office in every federal district has prosecutors specially assigned to prosecute fraud cases. And, every FBI and OIG Office has agents assigned to investigate healthcare fraud. Anyone who bills Medicare is a possible target.
Khouri Law Firm defends criminal investigations and defends against professional license disciplinary matters. Our firm understands the relationship between all these moving parts.
Consolidation of all issues leads to a better result at a reduced cost. We understand the importance of having experts in medicine, coding, billing processes, and statistical analysis of data that can be critical in reducing or eliminating any fines incurred. Khouri Law Firm will go on the offensive to get you the best possible outcome.
Medicare Fraud Defense Team You Can Trust
Michael J. Khouri has been practicing law in Orange County for over 30 years and is considered an expert in defense of Medicare audits. He specifically has a long list of experience with representing health care providers, leading to his great reputation throughout California for his integrity and dedication to getting his clients the best possible resolution to their licensing or criminal matters.
Khouri’s associates Behzad Vahidi, Esq. and Stephen DeSales are also passionate members of the fraud defense team. Behzad is an associate attorney of professional experience in criminal defense. Stephan is backed by over 50 years of experience and more than 250 jury trials, Stephan has defended thousands of clients while working with prosecutors and judges alike. Simply put, he has managed to build a reputation that many lawyers dream of. Hire the best medicare fraud attorney today!
Free Medicare Fraud Defense Consultation
Making sure you feel comfortable with your healthcare fraud attorney is the most important part of the process. We ensure to map out time in our schedule for free Medicare fraud defense consultations, giving you a better idea of what our Medicare fraud lawyers can offer. Additionally, we will happily share insights on your specific circumstances to make sure you feel prepared for the road ahead. Whether you are facing Medicare fraud charges or involved in a healthcare fraud case, call us today to take advantage of our in-depth industry experience and knowledge.
FAQ'S
What is Medicare Fraud?
Knowing the basics of Medicare fraud is crucial to understanding your own case and situations, and we want to make sure you are as caught up as possible. Medicare fraud generally refers to instances of submitting false claims to a government health care program, an issue that makes up about $50 billion in claims a year. Because of this, there is always a chance that you will be audited, no matter how much work you put into playing things by the books.
There are five statutes you should understand when it comes to Medicare fraud to fully grasp what you’re expected to comply with:
- False Claims Act: Knowingly submitting fraudulent statements to obtain federal health care payments to which the provider is not entitled.
- Stark Law: Making prohibited referrals to an entity in which the physician or their immediate family has ownership, financial interest, or a compensation arrangement.
- Anti-Kickback Statute: Knowingly soliciting, paying, or accepting remuneration to reward referrals for items/services that are reimbursed by federal programs.
- Civil Monetary Penalties Law: Presenting a claim that is for an item/service not provided as claimed or one that is fraudulent or false. This could also be for presenting a claim for an item/service not reimbursable by Medicare.
- Criminal Fraud Statute: Knowingly executing or attempting a scheme to defraud any health care benefit program or to obtain money/property owned by a health care benefit program by means of false pretenses.
Government Investigation: Civil or Criminal?
Medicare fraud is investigated in depth by many different parties, including the Office of Inspector General, the Department for Health and Human Services, the Department of Justice, the FBI, Medicaid Fraud Control Units, and State Medicaid Agencies.
If found guilty, both civil and criminal punishment could be in order depending on your specific situation. To paint a general picture, about 1,400 individuals are indicted while 2,500 are under Medicare criminal investigation, so the threat of criminal punishment is very real.
The best way to know what your specific situation entails is to really sit down and discuss it with you so that we can have a general idea. Just know that there is no guarantee that you will be under criminal investigation, so let us handle your case and determine the severity for you specifically.
What are Examples of Medicare Fraud?
There are many different examples of Medicare fraud, so it can be hard to keep track. Here are some commonly seen cases:
- Phantom Billing: this is submitting billing for services not provided and is one of the most common types of Medicare fraud. It could involve tests that were never taken, healthcare hours not provided, or even billing for patients who have already left or died.
- Double Billing: this is when the provider attempts to bill the patient, insurance company, or Medicare multiple times for the same treatment.
- Falsification of Cost Reports: this involves adding personal expenses under the guise of professional expenses related to treatment of patients. Cases of this have included billings for new cars, renovations, or other personal costs.
- Falsification of Patient Records: this can be done in order to falsely prove a need for gratuities treatments, prescriptions, or even surgeries for the sole purpose of billing.
- Kickback Fraud: this refers to instances when laboratories or pharmaceutical companies offer kickbacks through money, gifts, or products to providers in exchange for referrals.
- Physician Self-Referrals: as mentioned earlier, physicians may not offer referrals to facilities with which they have a conflict of interest (they or an immediate family member have financial involvement).
What is the Medicare Appeals Process?
With the complexity of Medicare fraud cases, there is, of course, an appeals process to understand as well. Taking on this process without experienced attorneys is a massive mistake that could lead to costly risks and penalties, many of which could be avoided.
The steps of the Medicare appeals process are:
- Redetermination by a CMS contractor (Centers for Medicare & Medicaid Services)
- Reconsideration by a qualified contractor
- Hearing before an administrative law judge
- Review by an appeals council
- Judicial review in federal district court
All five steps require meticulous care and attention to provide the correct evidence and argument to ensure success in moving forward. Be sure to have an experienced lawyer making these steps with you so that you are informed and prepared.
Book you free consultation with us to get started!
What is Healthcare Fraud?
In the most simple definition, Healthcare Fraud is the umbrella of all criminal acts involving the submission of a false claim, misrepresentation of fact, and acquisition of payment from a government health insurance program.
Today, healthcare fraudsters have been so strategic that they target persons working for or availing to the medical services, including your physician, medical representative, hospital staff, healthcare organizations, and healthcare insurances.
Healthcare fraudulent activities have taken around 30 billion to 140 billion dollars by attacking government services annually. Millions of lives have expired due to unlicensed medical operations and faulty healthcare services provided by medical fraudsters.
Be aware. The face of healthcare fraud is complex and compelling. It encompasses various healthcare schemes and programs with a hidden agenda to obtain your medical information, prior medical history, and hospital billings to be used against you.
Government Investigation: Civil or Criminal?
A government investigation on healthcare fraud cases starts when a private whistleblower calls the Centers for Medicare and Medicaid Services (CMS). The CMS validates the claim and maps out to ascertain a common scheme or a fraudulent pattern. If the CMS has found that the validity of the claim is sufficient for a case, then the case advances to either the Department of Justice (DOJ), Office of the Inspector General (OIG), or the Federal Bureau of Investigation (FBI).
These government authorities evaluate the nature and information of the case, dependent on what particular laws have been violated, either civil or criminal laws.
What are Examples of a Healthcare Fraud?
- Kickback fraud: This occurs when a particular laboratory or a medical clinic fraudulently induces an individual through money, gifts, or products in exchange for referrals.
- Physical Self-referral: This takes place by the efforts of a physician or referring patients to an entity that works for designated health care services (DHS). A physician can potentially benefit from such referrals since he or she has a financial interest in a medical entity.
- Upcoding: This is the best example for a healthcare provider who sends a bill to Medicare that contains exaggerating information of the time, procedures, materials involved, for the patient to pay a higher rate.
- Unbundling: Similar to Upcoding, this type of healthcare fraud also involves hyperbole of information. However, a healthcare provider submits multiple groups of procedural services, instead of a single-group service. As a result, a patient pays for a higher price caused by an evil scheme.
- Billing for Unlicensed Personnel: Healthcare fraudsters are quick thinkers that they can easily pretend as your legitimate physicians. In this type of healthcare fraud, healthcare service providers are unknowingly practicing and operating medical services without any proven medical certificates.
- Billing for Unnecessary Medical Services: You better check your healthcare bills before it’s too late. This type of healthcare fraud is a hype in common cases, where a healthcare service provider, at the precise moment of pricing, changes a particular provision of the services you availed without further notice. In worst-case scenarios, you can pay a higher price than what you expect.
- Defective Products and Manufacturing Violations: Healthcare fraudsters have a common pattern: they incite fear, provide sensationalized solutions, and sell unapproved and illegal products. More often, they involved manufacturers in releasing products for public use and consumption, and supported by influential personalities through personal testimonies on using the product.
What is the Healthcare Appeals Process?
The purpose of a healthcare appeals process is to resolve contractual disputes regarding payment disputes, false claims, and any related healthcare fraud issues. As per legal advice, you need to have a healthcare fraud attorney who has proven experiences in negotiating civil and administrative cases to avoid risks and penalties.
Here are the five steps of a Healthcare Appeals process:
- Redetermination by a CMS contractor (Centers for Medicare & Medicaid Services)
- Reconsideration by a qualified contractor
- Hearing before an administrative law judge
- Review by an appeals council
- Judicial review in federal district court
All five steps require meticulous care and attention to provide the correct evidence and argument to ensure success in moving forward. Be sure to have an experienced lawyer making these steps with you so that you are informed and prepared.
Book you free consultation with us to get started!
Mike Khouri is an Expert at Medicare Law with over 30 years and 500 Medicare Fraud cases under his belt. His expertise will lead to the best possible outcome. He sees a pathway to success where others do not.
