As with many other types of white-collar crimes, health care fraud cases often begin long before official charges enter the picture. Understanding what can lead to investigation and knowing the warning signs can help you take timely action to protect yourself.
Generally, health care fraud consists of purposeful misrepresentation, such as using the wrong codes for procedures, double-billing and other types of activities designed to get higher reimbursement than the provider deserves, whether from a private insurer or from the government.
How investigations begin
Today, law enforcement agencies that investigate health care fraud often use sophisticated computer algorithms that analyze the claims providers submit and flag suspicious billing patterns.
Examples of potential red flags may include claims for procedures typically outside a provider's area of practice or significant deviations from billing patterns of similar providers in the same geographic area. In other cases, an investigation can begin due to a complaint from an employee or patient.
In many cases, investigators may gather evidence for a while before sending you a letter notifying you of the investigation. Common tactics may include speaking with employees, patients and vendors or trying to gain access to your records.
Get help as soon as possible
You should speak with a qualified defense attorney as soon as you become aware of a potential investigation. Do not wait for the official letter.
An investigation is never a minor issue
Avoid speaking to anyone else about the investigation. Investigators may downplay the significance of the issue and tell you they just want a quick chat to clear things up. Unfortunately, that rarely turns out to be the case.
It is very easy for someone unfamiliar with the intricacy of the laws involved to incriminate him or herself by speaking too casually or mistakenly using the wrong phrasing. Likewise, do not allow access to your records until there is a warrant.
Some people panic and tell their employees to lie or try to change existing records. This is risky behavior that typically leads to even more severe charges. Instead, your attorney can advise you as to effective ways to protect yourself.