Allegations of fraudulent billing can negatively impact the physician who faces the accusations and their medical practice. It is important for both parties to take steps to protect their interests. It is helpful to learn from other cases to better prepare for the investigation and any resulting legal action. In a recent example, the Justice Department accused a neurosurgeon of billing Medicare for medically unnecessary spine surgeries. Three things every medical practitioner should learn from this case are discussed below.
#1: What triggers this type of case?
These investigations often start with data analytics identifying outliers or a whistleblower complaint. Depending on the information gathered in these early stages, the investigation can expand into a broader probe involving the Office of Inspector General, the Department of Justice and state licensing authorities.
In this example, a former patient initiated the case by filing a whistleblower lawsuit. Upon review, the government decided to join in and pursue further legal action.
#2: What are common defense strategies?
When a case hinges on medical necessity, one of the most important pieces of evidence to help build defense is medical records. Gather and organize documentation to show support for provided care. Expert testimony is also beneficial as it can show that other professionals would have provided the same care in a similar situation.
It can be helpful for the practice itself to gather documentation to support their reason for hiring the physician and evidence that establishes the physician as competent and, if applicable, an expert in their field.
#3: How can physicians and medical practices protect business operations?
It is important to take the allegations seriously and cooperate with the investigation, though best to do so with the guidance of legal counsel with experience in this niche area of law. Private practices and hospital organizations are wise to recognize that these investigations are rarely quick. This matter took more than six years to resolve. During this period, business operations must continue so that physicians can provide care to patients in need. The best approach while under investigation will depend on the particulars of the case.
In many situations, a physician can continue to practice while the investigation moves forward. In the case noted above, although the surgeon was initially allowed to continue to provide care the Department of Health ultimately stepped in and restricted him from continuing. Physicians and practices are wise to have plans in place to adapt as needed as the investigation and case move forward.
Physicians and medical groups that find themselves the subject of a healthcare fraud investigation should take action to protect their interests. Gather documentation and begin building a defense while navigating a business strategy that allows for continued operations. Legal counsel can advocate for your interests and help to mitigate the impact on your practice.
Attorney John Rivas is responsible for this communication.
