Wexford Law and Michael Devereux, Top Rated Attorney for Insurance Fraud Defense
Insurance fraud is a serious charge that can have devastating consequences, including everything one ever acquired and more. It can leave families devastated with their loved one and primary bread winner serving a long prison term. The client is likely to lose their license, their practice, their home, their cars, any investments and any cash that they have, along with other assets.
What is Insurance Fraud?
The majority of insurance fraud is committed by organized crime groups and a very small minority of dishonest health care employees. The most common types of insurance fraud according to CMS include: 1) Knowingly submitting, or causing to be submitted, false claims or submitting misrepresentations to acquire claims reimbursement from payers for which no entitlement exists; 2) intentionally soliciting, receiving, offering, and/or paying remuneration to encourage or reward referrals for items or services reimbursed by payers; and 3) providing prohibited referrals for specific designated health services.
How Can Providers Detect Insurance Fraud?
As value-based purchasing takes hold of the healthcare industry, providers are also seeing claims reimbursement rates drop in favor of incentive payments. Efforts to maximize revenue may push some providers and/or employees to engage in healthcare fraud and abuse activities without intending to, such failing to correct a billing clerk who assumes a provider performed specific services, billing for medications that patient never picked up, and coordinating with other provider organizations under value-based agreements. While providers may or may not intend to commit insurance fraud and abuse crimes, the federal government is as strict as ever with cracking down on insurance fraud schemes.
Federal False Claims Act
Imposes civil liability on any individual who knowingly submits, or causes the submission of, false or fraudulent claims to the federal government, law officials do not need proof of specific intent to defraud to charge individuals.
Targets individuals who knowingly and willfully pay, solicit, offer, or receive remuneration directly or indirectly to induce or reward referrals of services and items reimbursed by federal healthcare programs.
Physician Self-Referral Law
Prohibits providers from making referrals for services reimbursable by federal healthcare programs to an entity in which the provider (or family member) has an ownership or investment interest or a compensation agreement.
IMPLEMENTING A COMPLIANCE PROGRAM TO IDENTIFY AND PREVENT INSURANCE FRAUD
Developing a strong compliance program is key to preventing insurance fraud and abuse activities.
ADDRESSING DOCUMENTATION, CODING, AND BILLING PROCESSES TO AVOID MISCONDUCT
While a compliance program is the foundation for insurance fraud and abuse prevention, providers should also consider improving their medical billing and coding processes.
INSURANCE FRAUD LAWS COMPLICATE VALUE-BASED PURCHASING IMPLEMENTATION
Under value-based purchasing models, providers may seek business relationships with other organizations to fill care gaps. Controlling care across the continuum also allows providers to monitor patient outcomes and costs to maximize value-based reimbursement.
PENALTIES MAY INCLUDE PRISON & RESTITUTION
The penalty at conviction for insurance fraud can be steep, including years in prison, along with loss of home, cars, investment properties, airplanes, bank accounts, license, your practice, etc. At the end of the day, your loved ones can be displaced while you are serving time in prison.
Our experience includes representing phsycians, surgeons, dentists, pharmacies, and other providers. We discovered that early intervention of a skilled lawyer knowledgeable, not only in criminal insurance defense, but health care law as well is key. Insurance fraud prosecutions are highly specific prosecutions lead by the U.S. Attorney’s Insurance Fraud Division. Thus, the defense of such allegations requires highly specialized insurance fraud defense attorneys capable of analyzing a voluminous amount of health data with knowledge of billing practices, compliance issues and medical necessity.
Insurance Fraud Defense
Criminal insurance fraud convictions require proof beyond a reasonable doubt that an individual knowingly and/or willfully submitted a false claim or engaged in kickbacks or other fraud, including insurance fraud. However, proof of actual knowledge or specific intent is not required for a conviction. A person can be convicted if their employee is found to have acted with deliberate ignorance or reckless disregard of the truth or falsity of the claim. In some insurance fraud cases, the ultimate issue is simply whether the individual acted knowingly and/or willfully. In other cases, the issues are much more complex. For example, insurance fraud allegations involving worthless services, medical necessity or overutilization present an additional question regarding the standard of care. The federal government trend is to criminally charge physicians who allegedly prescribe/perform health care services that are not medically necessary. Our insurance fraud defense lawyers are uniquely suited to defend these claims. Our knowledge of conditions of payment, conditions of participation, with years of defending physicians provides us with the necessary knowledge to understand and apply the standard of care, DRG’s, CPT’s, clinical practice guidelines and conditions of payment in the defense of our clients.
Results Oriented - Wexford Law is Michael Devereux, Not A Law Firm By Committee
Results matter at Wexford Law. Our approach is client-oriented, and we are committed to providing the best results possible. Some law firms measure success by their growth in size. Yet, other law firms measure their success by profit. Our priority is to measure our success based upon results. You will not be shuffled off to a junior attorney. Your attorney will have close to 20 years of attorney experience from beginning to end. Our endeavour is to establish long-lasting relationships with our clients so that they can refer us to their friends and family.