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Healthcare Fraud Lawyer in Los Angeles

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The Right Defense for Healthcare or Medicare-fraud Charges

When it comes to healthcare this office is more than the typical attorney office - we know medical practice and healthcare law. This is a law office that for many years was a member of the American Health Lawyers Association, along with years of experience at many medical institutions including Molina Healthcare, Pacificare, Tenet Healthcare and Professional Healthcare Systems.

Our law library likely contains more material on Healthcare than likely any other law firm that you are considering. We have successfully represented doctors, nurses, chiropractors, pharmacists and providers in investigations involving the Office of Inspector General (OIG), Centers for Medicare & Medicaid Services (CMS), Safeguard Services, Medicare, Palmetto GBA, NHIC, Noridian, Drug Enforcement Agency (DEA), California Attorney General, California Board of Medical Examiners, California Board of Chiropractic Examiners, California Board of Orthotist, California Board of Nursing, United States Department of Health & Human Services (DHS), California Pharmacy Board and the United States Department of Justice. We know healthcare law.

Courtroom Experience

Michael Devereux is considered a Top 100 Trial attorney in the United States. In addition, he has been ranked in the top 3 trial attorneys in California. He has appeared in federal trial court, the Ninth Circuit Court of Appeals, California Supreme Court, California Appellate Court and California Superior Court. Michael Devereux is authorized to appear in all California Districts of the United States District Court. In addition, he has appeared in Arizona, Delaware and Illinois.

Healthcare Fraud

The healthcare system in the United States is ripe for fraud. Not only with the providers themselves but also with those acting on behalf of the government. The government has outsourced a great deal of their responsibilities in the system to special interests who have a stake in finding overpayments because the special interests are paid a percentage of what they discover. Right or wrong, as long as those with the special interest can make a case for their findings they will be awarded handsomely by the government. Initially the special interests went after large hospitals, only to discover that the large hospitals were difficult. Hence, the special interests now attack the small practices because the small guys typically don't have the resources to fight back.

What to Be Alert For During A MEDICARE Audit

Healthcare-fraud matters typically start in the same manner. One gets contacted by a Centers for Medicare & Medicaid Servicers (CMS) contractor such as Safeguard or Palmetto GBA for a quick 10 patient audit during a certain period of time generally 2 or 3 years. The audit is by law to be a random request, but it appears that there is some data mining to the request. Bear in mind that the contractors don't get paid unless they find something so it's good to have an internal audit done on the files before they are turned over. Even the slightest error is reason to ask for 20 more files. You want the CMS contractors to go away as quickly as possible so it's pertinent that the 10 files are perfect so by permitting an outside auditor the opportunity to audit the files before they are turned over may save millions of dollars and possible criminal charges. Besides it's good business sense to have an outside auditor come in at least once a year to review the files.

You don't want the CMS contractor to ask for 20 more files because the 20 files is significant since from a statistical analysis perspective 30 is the minimum number acceptable for a "sample." That is very important to know because later it will come back to haunt many because the CMS contractor may return a result that claims some percentage of your files are incomplete. In CMS' mind, an incomplete file is considered overpayment. At this stage of the process, there is no such thing as quantum meruit meaning that although you provided the service or the equipment you are not going to be paid for such. (The reason for the external audit is to catch those errors.)

Now CMS will request that your practice refund the funds. Remember that "sample?" Here's how it comes into play. Of those 30 files a certain percentage are considered an overpayment. There was a period of time that the 30 files were pulled from. During that period of time your practice received x amount of dollars. The government is going to request that your practice returns the percentage of x amount. For example, if CMS paid the practice $1,000,000 for three years and in that three years 30% of the files were incomplete then CMS is going to request from your practice a payment of $300,000.

Here's the kicker, the CMS contractor is going to be paid directly from the federal government a contingency fee close to 22% of the $300,000. Whether or not CMS collects from you the contractor is going to be paid roughly 22%. The reason that the contractor initially asks for 10 file because if there is nothing there then they are in and out without a lot of overhead. Once the CMS contractor asks for more files, their overhead increases and rest assure the CMS contractor will find something.

Typically, the next move is to ask for a redetermination, followed by a reconsideration and then an appeal. More importantly, the right healthcare attorney knows that it is time to nip in the bud any possible investigation of criminal charges. It is at this time that a comprehensive strategy and plan be implemented to protect your practice and your license.

Other Alerts Providing Notice of a Pending Criminal Action

Besides the payment suspension, in which Medicare/CMS stops making payments, the other alerts that one should be aware of include:

  1. Grand Jury subpoenas issued to your bank on your bank accounts.
  2. Government seizure/freezing of bank accounts and the confiscation of other assets such as home, car, other businesses, etc.
  3. Federal agents such as the FBI or DEA may contact you directly.
  4. Federal agents may contact your friends or colleagues.
  5. Execution of a search warrant.

Consult Wex Law Attorneys

You could benefit from meeting with Wex Law to discuss further. Unlike the typical criminal defense attorney, healthcare-fraud defense attorneys can do a number of things to mitigate or avoid the scenarios discussed above. More importantly, an experienced healthcare defense attorney is more likely to evaluate the early signs of an investigation and react accordingly to avoid criminal charges. Further, an experienced healthcare defense attorney will assist in keeping your practice up and running during the investigation, along with making the correct preparations in protecting the practice and you. Moreover, you will need to discuss a financial plan with your attorney to assist getting through the investigation. Don't plead guilty because you simply have no funds to defend yourself. Plan ahead. All consultations are free and confidential.

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Wex Law
1000 Wilshire Boulevard, Suite 2150
Los Angeles, California 90017
Phone: (844) 4WEX-LAW
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