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How does the government build a healthcare fraud case?

On Behalf of | May 5, 2023 | Health Care Investigations |

The government takes allegations of healthcare fraud seriously. It will aggressively investigate and look to move forward with prosecution if evidence supports the allegations. When investigating, the government will look for potential violations including billing services that were never rendered or medically unnecessary. They will also look for instances when the billing department used the wrong code to make a service that was provided qualify as a covered service even if it was not.

But how does the government find out about these potential violations? Why did the government chose to start an investigation on your facility? Three methods the government uses to find targets include algorithms, partnerships, and undercover operations.

#1: Algorithms

The government will use software to help flag facilities or individuals that have billing practices that fall outside of the norm. This can lead to an additional investigation to check for any wrongdoing.

#2: Partnerships

The United States Health and Human Services (HHS), Department of Justice (DOJ), and even Internal Revenue Service (IRS) will work together to gather evidence to build these cases. This can mean one agency notices an issue and alerts the others, leading to an audit or further investigation.

#3: Undercover operations

In a recent example, the government used undercover agents to gather evidence to build a case against a supposed healthcare fraud scheme taking place in New York and New Jersey. For this operation, an agent posed as an Amtrack employee and visited a doctor’s office. The government believed this physician was part of a group that was targeting Amtrack employees for a healthcare fraud scheme that began in 2019. The government is currently building a case that claims the group would set up a deal with the employees. In exchange for their insurance information the group would give the workers cash and then file false claims. The government claims the scheme cost Amtrack millions in fraudulent claims.

Based on the results of this operation the undercover agents were able to gather enough evidence to arrest four individuals and the government is currently moving forward with prosecution. The accused face ten years imprisonment and hundreds of thousands in fines if convicted of these crimes.

At the end of the day, the how is only part of the problem. It is important to take any investigation seriously and start building a defense that is tailored to your situation to help better ensure a favorable outcome.

Attorney John Rivas is responsible for this communication


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