Getting a letter that accuses your business of healthcare fraud can be very unsettling. You may even be having a hard time determining whether it’s an audit notice or a formal complaint. At first, you assume there must be a misunderstanding, but as the investigation unfolds, you realize how complex and overwhelming the process can become.
For business owners, healthcare fraud and abuse allegations are no small matter. They can jeopardize your finances, your reputation, and even the future of your business. Whether the claims are based on a mistake or something more intentional, understanding what constitutes healthcare fraud and abuse (and how to respond) is critical.
At SKT Law, we work with countless business owners facing these challenges. If you’re facing a similar scenario, we will break down healthcare fraud and abuse, explore how these issues arise, and explain why having an experienced legal team is essential to navigating the road ahead.
What is Healthcare Fraud and Abuse?
Healthcare fraud refers to intentionally deceptive practices designed to secure unauthorized financial or personal gain from a healthcare program, insurance provider, or government entity. Abuse involves activities that result in unnecessary costs to healthcare programs but lack intent to defraud. While the two terms differ, both can lead to significant legal and financial repercussions.
Examples of healthcare fraud include:
- Billing for services not rendered: Charging for procedures or treatments that never happened.
- Upcoding: Submitting claims for more expensive procedures than those actually performed.
- Kickbacks: Offering or accepting illegal incentives for referrals or contracts.
Healthcare abuse may involve practices such as excessive billing for unnecessary treatments, overutilization of services, or improper use of medical resources.
“Fraud and abuse cases require a close examination of both intent and compliance. Even small errors in documentation can trigger major investigations, which is why thorough legal analysis is key,”
- Eliot Krieger, Managing Partner, SKT Law
Why Are Allegations of Healthcare Fraud So Common?
The healthcare industry loses more than $100 billion annually to fraud and abuse, according to the U.S. Department of Justice. This staggering figure means businesses are often under heightened scrutiny from auditors, payers, and regulatory agencies. Even unintentional errors, such as incorrect billing codes or misfiled paperwork, can spark investigations.
For business owners, this scrutiny can feel overwhelming. Even if your business operates ethically, complex healthcare laws and regulations leave little room for mistakes. Understanding how to protect yourself starts with recognizing the scale and nature of healthcare fraud allegations.
What to Do If You’re Accused of Healthcare Fraud or Abuse
If you’re facing accusations of healthcare fraud or abuse, the way you respond can make or break your case. Here’s how to take action:
1. Consult Legal Counsel Immediately
Do not attempt to resolve allegations on your own. An attorney in healthcare law will help you understand the scope of the investigation, gather necessary documentation, and develop a defense strategy.
“Healthcare fraud investigations often come with tight deadlines and high stakes. Having legal counsel early ensures that your response is timely and thorough,” says Eliot Krieger.
2. Preserve Evidence
Document everything related to the allegations, including billing records, contracts, and communications. This evidence will be critical for your defense.
3. Avoid Contact with Accusers
Engaging with auditors, payers, or other parties directly can complicate your case. Let your attorney handle all communications to prevent further misunderstandings or misstatements.
Related Article: What to Do When Facing a Healthcare Lawsuit or Investigation
Building a Strong Defense
One of the most important elements in healthcare fraud cases is intent. Was the issue a result of deliberate wrongdoing, or was it an honest mistake? A strong legal defense focuses on disproving intent while demonstrating that your business is committed to compliance.
Proving compliance may involve:
- Showing records of regular audits and training.
- Presenting documented efforts to follow healthcare regulations.
- Highlighting swift action taken to address errors or concerns.
By demonstrating your commitment to ethical practices, you can mitigate potential penalties and rebuild trust with stakeholders.
How SKT Law Can Help
Healthcare fraud and abuse cases are complex, requiring a combination of legal expertise and industry knowledge. At SKT Law, we specialize in defending business owners accused of fraud or abuse. Our team conducts thorough investigations, challenges the evidence, and works to protect your rights and reputation.
From negotiating settlements to navigating audits and court proceedings, we’ll stand by your side every step of the way.
Schedule a Consultation Today
Don’t let allegations of healthcare fraud or abuse put your business at risk. Schedule a consultation with SKT Law today to discuss your case and develop a strategy for moving forward. With our experience and commitment to your success, you can protect what matters most—your business, your reputation, and your future.