Expert HealthCare fraud attorney
Michael J. Khouri has been practicing law in Orange County for over 30 years and is considered an expert in Healthcare fraud defense.
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Tackling complex cases & seeing them through
When you are under investigation for phantom billing, 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 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.
Healthcare Fraud Defense Lawyers
For over 30 years, Khouri Law has maintained successful defense strategies in healthcare fraud cases. The firm’s founder Michael Khouri, and other high-caliber healthcare fraud defense lawyers, have proven results and experiences in litigating Stark Law, False Claims Act, federal and state anti-kickback statutes, criminal pleas, trials, and sentencing and more.
Khouri Law values a collaborative approach in all dealings through promoting respect and reverence to all stakeholders. For us, you’re not just “another client.” We value our partnerships and treat every individual like family.
We have successfully represented employers, contractors, physicians, and hospital staff in numerous issues. We are ready to defend you.
Healthcare Fraud Defense Team You Can Trust
Whatever it takes. These three words form a dynamic, dedicated, and disciplined healthcare fraud defense team that you can trust. From their outstanding experiences to finding their common legal aspirations, Khouri Law healthcare fraud defense team stands with your interests, from the beginning until the end.
Book a Healthcare Fraud Defense Consultation
Khouri Law is a client-first law firm that puts your interests above all else. Protecting your finances and your confidential data, including your healthcare insurance, medical information, prior medical history, and hospital billings, is the essence of our legal service. We believe in diverse community support, and we strive for an inclusive climate of legal protection against healthcare fraud cases.
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.
The False Claims Act (FCA)
Better known as Lincoln Law, the False Claims Act criminalizes any health care organization or health care service provider, suspected to commit reckless ignorance, in making a false record, or filing a false claim to any healthcare programs funded by the U.S. government.
It empowers a private citizen to become a whistleblower or a “relator,” bringing a case on behalf of the government.
The Stark Law
The Stark Law seeks to ban physicians’ referrals to a patient covered by Medicare or any state-sponsored costs for designated healthcare services (DHS) only.
As a general rule, violators of the Stark Law are required to refund any payments received as a result of the referral. However, to avoid civil liabilities, there are existing exceptions that the law provides.
Civil Monetary Penalties Law (CMP)
The Office of the Inspector General may seek a CMP or exclusion against an individual that presented a false claims on items or services not provided, involved in kickbacks, misrepresented a material fact to received funds under an HHS grant, contract or other agreement, negligently violated its obligation under EMTALA, and who didn’t not follow regulatory requirements of Public Health Security and Bioterrorism Preparedness and Response Act of 2002.
The Anti-Kickback Statute (AKS)
The Anti-Kickback Statute inhibits the exchange of remuneration to anything of value, to induce referrals, of Medicare and Medicaid business.
It is different from the Stark Law, since it highly requires the intent of a violator, and it applies to any referral sources, whether to Medicare or any federal healthcare program.
Criminal Healthcare Fraud Statute
Under the U.S. Code, any person who intentionally commits to defraud any healthcare benefit programs, or to use fraud and false statements to obtain funds held by a federal healthcare program, shall face up to 10 years in prison and shall pay a fine up to 500,000 dollars, or twice the amount of the fraud.
What are Examples of a Healthcare Fraud?
Kickback fraud occurs when a particular laboratory or a medical clinic fraudulently induces an individual through money, gifts, or products in exchange for referrals.
Self-referral 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 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.
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.
Do you need a Healthcare Fraud Attorney?
Have you ever experienced being scammed by a healthcare service provider through subscribing to a fraud monthly insurance or billed by services not rendered? How did you respond when you knew that a physician had falsified your diagnosis to justify your laboratory tests that weren’t necessary? How did you react when a hospital billed for a higher-priced treatment than its actual price?
If these questions amplified your silence, it is the right time to find the best healthcare fraud attorney who will consult and represent your case against healthcare fraud cases.
Healthcare Fraud is a complex and compelling issue. If you’re going to solve it by any professional other than a healthcare fraud attorney, chances will be a loss in your part.
At Khouri Law, we don’t want you to miss any parts of justice. That’s why you need a healthcare fraud attorney for three core reasons: competence, connections, and character.
A healthcare fraud attorney has a competent legal background in counseling and litigating on the most sensitive and crucial healthcare cases, involving the False Claims Act, Anti-Kickback Statutes, the Stark Law, Civil Monetary Penalties Law, and Criminal Healthcare Fraud Statutes. These laws are crucial to deal with, especially when you don’t hire a proper professional who can help you.
The reputation of a healthcare fraud attorney lauds to represent most healthcare service providers, including doctors, nurses, hospital staff, surgeons, physicians, and other medical front liners. His connections have built trust and partnership as an edge in winning healthcare fraud cases, especially that he establishes an excellent mastery in both medical and legal knowledge.
One thing that a healthcare fraud attorney values is his mission to increase your morale and bravery in exposing healthcare fraud issues without anyone to fear. His encouragement manifests from his compassion and dedication in protecting you against odds. That’s why choosing a healthcare fraud attorney is a long-term investment. Because when you are in the final rows of your liberty, he stays with you, whatever it takes.
What is the Requirement for Healthcare Fraud Conviction?
The requirement for the conviction of a healthcare fraud depends on what specific law has been violated, either civil or criminal penalties.
In civil penalties, the plaintiff requires a preponderance of evidence to succeed in a civil case. If convicted, the defendant usually needs to pay civil penalty fines.
False Claims Act
If a healthcare fraud is convicted with the violation of the False Claims Act, he is required to pay a civil penalty between $5,000 to $10,0000, paying the government three times the amount of damages for a sustained false claim.
The Stark Law
The referrals and claims of Stark violators are each punishable by a $15,000 civil money penalty.
Any claim paid from improper referral results to a government overpayment. Hence, it requires a violator to pay $100,000.
Civil Monetary Penalties Law
If OIG succeeds in proving the civil liability through a preponderance of the evidence, the defendant needs to pay civil penalties that range from $2,000 to $100,000 for each violation, depending on the specific misconduct committed.
In criminal penalties, the prosecuting party must prove that the accused is guilty beyond reasonable doubt. If convicted, the defendant is required to be imprisoned in a penal institution, and pay restitution to compensate the victim for losses as a result of healthcare fraud.
Anti Kickback Statute
When convicted with Anti-Kickback Statute, a violator will serve a five-year imprisonment, pays fines up to $25,000, and excludes from the Medicare and Medicaid programs for at least five years.
Criminal Healthcare Fraud Statutes
If a violator is convicted with criminal healthcare fraud statute, he shall face up to 10 years in prison, and pay a fine up to 500,000 dollars, or twice the amount of the fraud.
Who is investigated?
Healthcare fraud laws generally apply to any individual or business, directly or indirectly, connected with and pays for services regulated by the U.S. government, including:
- Healthcare service providers (physicians, nurses, medical representatives, hospital staff, and among others)
- Laboratories (toxicology, biologics)
- Physician-owned entities
- Pharmacies (incl. compound)
- Designated healthcare services
- Medical Device Companies
- Private whistleblowers
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:
1st. Redetermination by a CMS contractor (Centers for Medicare & Medicaid Services)
2nd. Reconsideration by a qualified contractor
3rd. Hearing before an administrative law judge
4th. Review by an appeals council
5th. Judicial review in federal district court
Make sure that your fight against healthcare fraud marks a history in winning against injustice. In whatever it takes, make a victorious history against healthcare fraud with Khouri Law.