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Government and health-care fraud, Part 2: Investigations

As noted in the previous piece, Government and health-care fraud, Part 1: Why the crackdown?, the United States government has stepped up its efforts to prosecute those who are accused of health-care fraud. The main motivation for these efforts is money. The government stands to lose billions every year through this form of crime.

It is important the government goes about its investigations into allegations of health-care fraud wisely. A failure to do so could lead to false allegations of wrongdoing. This piece will focus on the government’s efforts to investigate allegations of health-care fraud. It will also touch on what medical professionals and others who are accused of these crimes should do to protect themselves from the allegations.

How does the government investigate allegations of health-care fraud? The government has taken steps to modernize its investigative efforts. This includes the use of technology during investigations.

A recent piece in the New York Law Journal discusses these new investigative efforts. The main example involves the use of data mining. This process essentially involves the review of large portions of data, looking for any anomalies. It involves a combination of predictive analytics and algorithms to flag potential violators. A provider that is found to bill at an excessive rate compared to his or her peers, for example, could be red flagged and investigated as a result of this process.

How can medical professionals protect themselves if the government accuses them of health-care fraud? The government has made it clear that it will “continue to aggressively combat health-care fraud in the year ahead.” Medical professionals should take note of these efforts and ensure their practices are in line with the law.

Defenses are available if the government investigates and you are accused of a crime. The best defensive strategy for health-care fraud allegations depends on the details of the accusations. Examples can include a review of the evidence for errors and a review of whether or not the accused was operating within the accepted standard of care. An attorney experienced in these matters can review your situation and tailor a strategy for the case, better ensuring a favorable outcome.

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