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Anatomy of a healthcare fraud case: 3 things to know

On Behalf of | Apr 20, 2022 | Health Care Investigations |

Healthcare fraud is a serious problem, and it is one the government will aggressively pursue. But how does the government build a healthcare fraud case? This piece will delve into the anatomy of these cases, so that those who may face allegations of wrongdoing can have a better understanding of what is happening and how they can protect their interests throughout the process.

#1: Receive notification of potential abuse.

The government will receive notification of potential abuse a number of different ways. Two examples are either a red flag through the use of analytical software or a whistleblower complaint. A whistleblower, or qui tam, case involves someone with inside information filing a claim on behalf of the government. This individual could be a worker within a hospital or insurance company or a c-suite executive.

The government incentivizes qui tam cases by allowing the individual who files the claim a share in any winnings if the claim is successful — and these payouts can be large. In a recent example, a manager at an insurance company has accused the group of overbilling Medicare billions. Even a small percentage of a payout that large is huge incentive to file a claim.

#2: Investigate.

If the claim seems promising, the government will join and investigate. This is often done in collaboration with state and local law enforcement programs and can include data analysis of claims for payment as well as medical review related to the claims for reimbursement to establish medical necessity of the service and appropriateness of the claim.

This is one point where the target of the investigation may become aware of the government’s concerns, as it can include the use of a warrant to gather evidence.

#3: Build the case.

If not yet aware of the investigation, the target of the allegations may receive notice of the investigation or a lawsuit at this time through a mailed notification. The government will then move forward with the case.

Negotiations are likely, but it is often wise to move forward with legal representation. An attorney experienced in healthcare fraud matters can advocate for your interests during these negotiations and work to better ensure your rights are protected throughout the process.

Attorney John Rivas is responsible for this communication

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