Healthcare Fraud Investigations Often Start with Audits—Not Arrests

In nearly every case, a federal healthcare fraud prosecution doesn’t simply begin with an arrest. More often than not, these cases start with an investigation triggered by an audit that occurs long before charges are filed. While audits are routine in most cases, they can also trigger an investigation by federal authorities.

The difficult thing about these cases is knowing which type of scrutiny you face. A request that appears focused on billing compliance can become more serious as investigators review records, compare claims, and interview employees. If an audit raises concerns about potential fraud, speaking with a federal criminal defense lawyer early gives you an opportunity to understand the government’s concerns and potentially avoid a criminal charge.

Why Do Healthcare Fraud Cases Often Begin With an Audit?

Audits give government agencies and healthcare programs an opportunity to examine billing practices before deciding whether more serious enforcement is appropriate. An audit can identify incorrect claims, unusual billing patterns, or other issues that warrant further investigation.

These audits can review a variety of practices and records. Auditors may then request patient charts, billing records, treatment documentation, or other information supporting selected claims. The initial question may simply be whether the practice received reimbursement it was not entitled to.

However, the situation can change if reviewers believe the records suggest intentional misconduct. In short order, a routine audit could lead to a federal prosecution.

What Can Trigger a Healthcare Billing Audit or Investigation?

Healthcare audits and investigations can begin for many reasons, and an audit doesn’t necessarily mean the government already believes you committed fraud.

Government healthcare programs have access to extensive claims data, and this can be used in a fraud case. Investigators can compare your billing with previous claims from your practice or with claims submitted by similar providers to get a clear picture of whether anything is unusual.

Current and former employees can also play an important role during or after an audit. An employee may report suspected false billing, unnecessary services, improper referrals, or other conduct to federal authorities. Some healthcare fraud cases begin with whistleblower allegations that provide investigators with information unavailable through billing data alone.

What Should You Do After Receiving an Audit or Records Request?

Take an audit or government records request seriously, but don’t assume criminal charges will follow. Attorney Lee Harville knows how these cases play out, and he suggests the following when you receive an audit request.

• Read the request carefully: Identify who issued it, what records the government wants, which claims or patients are involved, and when you must respond. The scope of the request may also indicate what investigators are examining.
• Preserve relevant records: Keep patient records and other potentially relevant materials, and collect them as soon as you can after you are notified of the audit.  
• Do not alter existing documentation: Never make changes to patient charts or billing records to make them appear more complete.
• Be careful about discussing the audit with employees: Do not instruct employees on what to tell investigators or try to coordinate explanations.
• Avoid guessing when responding to questions: Do not explain billing practices unless you know they are accurate.
• Contact a federal criminal defense lawyer: A lawyer can review the request, determine whether it raises potential criminal concerns, and help you respond without unnecessarily increasing your exposure.

An audit may remain an administrative matter, but there’s no way to be certain that’s how things will play out. Your best bet is to protect yourself throughout an audit.

Frequently Asked Questions

Does a Medicare audit mean you are under criminal investigation?

No. Medicare audits can occur for administrative and compliance reasons without leading to criminal charges.

Should you handle an audit without a lawyer?

You’re not required to assume every audit needs criminal defense representation. However, it’s a good idea to speak with a lawyer any time questions turn to potentially fraudulent acts.

Can federal investigators interview employees during a healthcare fraud investigation?

Yes. Investigators may contact current and former employees to ask about billing procedures, management instructions, patient care, internal concerns, and other practices.

Can correcting billing errors prevent criminal charges?

Corrective action can provide important evidence of good faith, but it doesn’t guarantee that an investigation will end. The government may still examine what you knew before discovering or correcting the problem.

How Can a Federal Criminal Defense Lawyer Help During an Audit?

A federal criminal defense lawyer can help determine whether an audit involves a routine reimbursement dispute or facts that could create criminal exposure. In some cases, it may not be immediately obvious that you face criminal jeopardy as an audit runs its course.

A lawyer can review the government’s requests, examine the billing practices at issue, and identify potential explanations before investigators draw conclusions from incomplete records. If federal agents request an interview, a lawyer can also advise you about whether and how to respond.

Reach Out to The Harville Law Firm, LLC Today

There’s no question an audit can be stressful, but it won’t always lead to a knock at your door by federal investigators. However, audits can still trigger criminal charges, even after you’ve corrected an honest mistake.

The Harville Law Firm, LLC is here to serve as your advocate during this distressing time. Instead of facing off with the government on your own, rely on attorney Lee Harville to help you fight back. Contact us for a confidential consultation today.