Criminal Law
DUI Defense
White Collar Crime
Medicare/Medicaid Fraud
Gun Charges

Medicare Fraud Attorney | St. Petersburg

If you believe you are being investigated for Medicare Fraud in the St. Petersburg area, you will want to hire an experienced lawyer like Scott J. Flint as soon as possible.  Even if you are being "audited" by Medicare, you should be aware that oftentimes these audits can lead to criminal investigations.  To understand why, one must understand the Medicare program billing system and the auditing process.  Most of the auditing is performed by private contractors.  But make no mistake: they are always welcome to discuss their findings with federal law enforcement.

Medicare and the Auditing Process

Medicare is a federally-funded health insurance program for the elderly and disabled, overseen by the Secretary of the United States Department of Health and Human Services (“DHHS”) DHHS exercises its authority to administer Medicare through the Centers for Medicare and Medicaid Services. The Medicare Act, 42 U.S.C. § 1395 et seq., is, in turn, administered through private organizations that contract with the DHHS. The Medicare program is divided into four main parts. Part A provides insurance coverage for inpatient hospital care and other institutional services. Part B is a voluntary program that provides supplemental medical insurance for, among other things, covered “medical and other health services,” including physician services, and medical supplies such as durable medical equipment (“DME”). Part C of Medicare governs the “Medicare Advantage” program, which offers Medicare beneficiaries a managed care alternative to the traditional Part A and Part B fee-for-services system. Part D provides a prescription drug benefit program.

Pursuant to statutory provisions in effect prior to October 1, 2005, Medicare Part B was administered by organizations known as “carriers.” Carriers entered into contracts with the Centers for Medicare and Medicaid Services (“CMS”). The obligations undertaken by carriers under those contracts include paying for items Medicare suppliers provide to Medicare beneficiaries, adjusting any incorrect payments, and recovering overpayments when the carrier concludes an overpayment was made for a covered Medicare benefit.

As a result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the obligations previously imposed on carriers are now undertaken by Medicare Administrative Contractors (“MACs”). MACs enter into contracts with CMS to perform various duties, including assisting in the administration of the Medicare Integrity Program.

Pursuant to the Medicare Integrity Program, entities known as “Program Safeguard Contractors” (“PSCs”) contract with CMS to perform various program integrity tasks to “safeguard” Medicare payments on behalf of the Secretary. The responsibilities of PSCs include auditing Medicare payments for potential fraud and ensuring that amounts billed under the Medicare program are appropriate and supported by proper documentation.

One common method used by PSCs to determine when an audit is appropriate is by identifying unusual or atypical billing patterns. Medicare claim information is stored electronically and auditors can easily identify providers whose billing patterns for a particular procedure or procedures are different from their peers. These providers are referred to as “outliers.”  Once a PSC decides to audit a provider, they often use statistical sampling and extrapolation to determine whether a provider has overbilled Medicare and to estimate a total amount of overpayments.

Medicare audits are one of several things that can trigger a larger civil or criminal investigation by federal law enforcement.  Therefore, if you are being "audited" by one of the entities listed above, it is important that you call me right away.

Medical Fraud Cases in St. Petersburg

Medicare fraud is typically prosecuted under a federal statute, 42 U.S.C. § 1347, which provides:

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-

(1) to defraud any health care benefit program; or

(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program,

in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned no more than 10 years, or both. If the violation results in serious bodily injury ... such person shall be fined under this title or imprisoned not more than 20 years or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life or both.

By the plain language of the statute, one violates Section 1347 if he or she engages in a scheme or artifice to obtain the money of a health care benefit program by means of false representations in connection with either the delivery of or the payment for health care benefits, items or services.

This is a sweeping statute and is designed to capture virtually any type of scheme to obtain money from Medicare unlawfully. And it works. In 2012, a task force working in seven cities led to 91 individuals, including doctors and nurses, being charged for their alleged participation in medical billing fraud totaling $432 million.  A 2013 task force working in eight cities charged 89 people, again including doctors and nurses, with fraudulenlty billing federal health care programs $223 million.  Almost 400 law enforcement officials participated in these operations.

How Will A Conviction Affect Your Life?

A criminal conviction for Medicare Fraud can devastate your career.  Your license can be suspended or revoked. Here in St. Petersburg, Florida, the Department of Health can refuse to issue or renew a license to any healthcare provider who has been convicted of, or entered a plea of guilty/no contest to a health care related felony until, at a minimum, ten years have elapsed since the sentence or term of probation or other form of supervision has ended. You will also likely be excluded from participating in federal health care programs for at least five years.

How an Attorney Can Help

Before practicing in St. Petersburg, Scott Flint was an Assistant Attorney General in the Medicaid Fraud Control Unit and has extensive experience with the statutes and regulations governing federal and state health care progams and the auditing process, including the use of statistical sampling to determine overpayments.  As noted above, the federal and state governments use the auditing process to identify "outliers" and unusual billing patterns.  While these patterns may be sign of "fraud," more often they are simply signs of innocent errors or a misunderstanding of the complex billing rules. Nevertheless, the government frequently decides to use criminal prosecution when civil recoupment would be more appropriate. If a experienced health care fraud attorney can get involved during the auditing process, he or she may be able to assist the auditors and present alternative explanations for the billing patterns other than fraud.  This could head off a referral to criminal prosecutors altogether.

The first line of defense against a Medicare Fraud prosecution or even an audit finding of overpayment is to have a good compliance program in place.  Yet even with such a program, some medical providers will get caught in the net cast by overeager prosecutors or aggressive auditors.  If this should happen to you, call Scott Flint Law Firm.  The quicker you get an experienced attorney involved in the case, the better chances you have of gaining a positive outcome. 

These cases can be extremely complex and detailed, meaning you want a forceful Medicare Fraud attorney on your side to protect you, your medical license, and your rights.

Call us today in St. Petersburg or Clearwater at 727-483-8404 for a consultation. 

Please Note
Contact Details
image 727-483-8404
image 111 2nd Avenue NE, Suite 704
St. Petersburg FL 33701