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False and Fraudulent Claims

The single most-powerful tool that the federal government has for prosecuting doctors suspected of fraud is the False Claims Act. This Act is an extraordinarily broad statue that imposes civil and criminal penalties for any and all “false or fraudulent” claims submitted for federal health care program reimbursement.

False claims refers to all coding errors, illegal forms of remuneration, and other health care law violations and can all lead to FCA liability. However, a key limitation of the FCA is that it imposes penalties only where a provider “knowingly” submits a false or fraudulent claim, or where a provider “acts in reckless disregard” of the truth in order to remain willfully ignorant of a billing violation. The government has a number of methods that it uses to prove this actual knowledge, but understand that Khouri Law Firm can implement various defenses to combat FCA liability.

There are two ways that physicians and other health care providers can become targets of the False Claims Act investigations. The first way is by direct government observation of trends, usually when Medicare data trends suggest an “abnormally” high billing record that is indicative of possible false claims. The second is through what is known as a qui tam lawsuit (whistleblower), where a private citizen with information about an alleged violation submits a case to the U.S. Department of Justice (DOJ) or the Department of Health and Human Services.

Civil Investigative Demand

A civil investigative demand is defined as any inquiry conducted by a commission or investigator for purposes of ascertaining whether any person is or has been engaged in unfair or deceptive acts or practices affecting commerce. It is a civil (not criminal) investigation. The problem is that the Federal Government is now using CID's as a guise for a criminal investigation.

The government requests information in the less threatening form of CID in hopes that the evidence in a medical billing fraud case will be handed over more readily. In reality, you may already be facing a criminal case. DO NOT TURN OVER ANY BILLING RECORDS TO THE GOVERNMENT WITHOUT SPEAKING TO AN ATTORNEY FIRST. Khouri Law Firm knows how to handle Civil Investigative Demands. Call Mike Khouri at (949) 680-6332.