Healthcare Fraud Investigations and Defense
A healthcare fraud investigation can put a provider’s freedom, practice, reimbursement, and professional license at risk at the same time. The response should begin with the actual allegation, the records behind it, and the decisions that cannot wait.
Charles Rollins represents individuals and businesses facing healthcare fraud allegations and related government investigations. His experience includes healthcare fraud defense, controlled-substances cases, professional license defense, and the financial records and electronic discovery that complex cases require. Based in Augusta, with office space in Atlanta, he is admitted in Georgia and North Carolina and handles matters nationally, subject to the requirements of the court involved. More about Charles’s experience and admissions.
Is this a billing dispute, a civil investigation, or a criminal case?
The first document matters. A payer’s audit request, a civil investigative demand, a grand jury subpoena, and a search warrant call for different responses. Counsel should identify the issuing authority, requested records, deadlines, and available objections before anyone treats the matter as a routine billing correction.
The same underlying conduct may be examined through several legal frameworks:
- Criminal healthcare fraud. 18 U.S.C. § 1347 addresses knowingly and willfully executing, or attempting to execute, specified schemes involving a healthcare benefit program. Under 18 U.S.C. § 24, that term includes qualifying private plans as well as public programs. A case need not involve Medicare to present federal criminal exposure.
- Civil False Claims Act liability. 31 U.S.C. § 3729 addresses specified false claims and related conduct involving government money. Its knowledge standard includes deliberate ignorance and reckless disregard; specific intent to defraud is not required. Potential remedies include treble damages and adjusted per-claim penalties.
- Referral and financial-relationship rules. The Anti-Kickback Statute and physician self-referral law have different elements, exceptions, and consequences. An arrangement’s treatment under one does not settle its treatment under the other. HHS-OIG explains the principal federal fraud and abuse laws.
Those distinctions affect the evidence and the response. Criminal guilt requires proof beyond a reasonable doubt. Civil liability and administrative sanctions follow different standards and procedures. A response designed for one proceeding should be assessed for its effect on the others.
Does a coding error establish fraudulent intent?
An incorrect claim does not, by itself, answer what a particular person knew or intended. The defense needs to reconstruct how the claim was generated: who documented the service, who selected or changed the code, what the billing system supplied automatically, and what the person approving the submission actually reviewed.
Useful records often include contemporaneous coding guidance, payer communications, training materials, rejected claims, internal questions, and the response to earlier audits. Records showing warnings or unresolved concerns matter too. Counsel needs the complete history rather than a collection of favorable examples.
For civil False Claims Act claims, the Supreme Court’s decision in United States ex rel. Schutte v. SuperValu Inc. focuses the knowledge inquiry on what defendants actually believed and knew. A reasonable interpretation developed after submission does not automatically defeat evidence that a claimant understood its claims to be false when made. The practical implication is to preserve the contemporaneous record, including how uncertainty was identified and addressed.
What evidence should the defense examine first?
The clinical and financial records need to be connected, not reviewed as separate stories. An early review may trace representative claims from the patient encounter through documentation, coding, submission, payment, adjustment, and any refund. Depending on the allegation, important materials include:
- Original patient records, orders, medical-necessity documentation, and electronic health record audit trails.
- Claim files, remittance records, billing-system settings, and communications with billing vendors.
- Referral, marketing, compensation, and ownership agreements, together with evidence of how they operated.
- Emails, messages, access logs, and records showing who made or approved disputed decisions.
- The government’s sampling method or financial calculations, when available, and the assumptions needed to test them.
Preserve originals and relevant system history. Do not backdate a note, rewrite a chart, or “clean up” an account to make an earlier event look different. Legitimate ongoing patient care and necessary corrections require a process that preserves the original record and accurately identifies later entries. Counsel can help coordinate preservation with clinical operations and privacy obligations.
Should the practice explain the problem or offer repayment immediately?
The appropriate response depends on the process, the evidence, and any applicable reporting or repayment duties. A volunteered explanation can become important evidence. A refund may address an obligation without resolving criminal allegations, licensing exposure, or the meaning of earlier submissions.
Counsel should promptly assess deadlines and duties while determining who is authorized to speak, what has been verified, and whether any proposed disclosure is complete and accurate. Neither a rushed admission nor an indefinite delay is a sound default. If agents request an interview, seek legal advice before agreeing to a substantive interview; do not obstruct a lawful search or ignore compulsory process.
Can one lawyer represent the practice and everyone who works there?
That question should be resolved early. The practice, owners, clinicians, and billing employees may have different interests. An internal interview conducted for the practice does not necessarily mean its lawyer represents the employee personally. The engagement should identify the client, the scope of the representation, and whether separate counsel is needed.
A coordinated defense also considers continuity of patient care, payer relationships, and professional standing. Certain convictions trigger mandatory federal healthcare-program exclusion, while other circumstances permit discretionary exclusion. HHS-OIG’s overview explains why exclusion consequences deserve attention before a resolution is accepted. State licensing proceedings require their own analysis.
A defense grounded in the practice’s actual work
Charles’s healthcare fraud experience is supported by work with experts, extensive electronic discovery, compliance matters, and related civil, regulatory, and licensing proceedings. The work begins with understanding how the practice operated and testing the government’s account against reliable evidence. Where the origin of investigative evidence is in question, see his analysis of concealed evidence sources and defense discovery.
To discuss representation, call (706) 814-2361. At the outset, identify the people and entities involved, the issuing agency, and any immediate deadline. Please do not send patient records or confidential details before representation and a suitable method of transmission are agreed upon.
This page provides general information, not legal advice. The applicable law and available defenses depend on the allegations, facts, and jurisdiction. Contacting the firm does not create an attorney-client relationship.