Hospitals, Medicare Advantage MSOs, pharmacies, laboratories, physicians, and executives, in government fraud investigations, insurer litigation, False Claims Act cases, and licensure and exclusion proceedings.
A fraud allegation in this industry is rarely just about money. It can suspend payment on pending claims, trigger a parallel referral to federal authorities or to the state, put a professional license at risk, and end in exclusion from federal health care programs. For a practice that depends on reimbursement to operate, those consequences arrive long before any judgment does.
We represent hospitals and hospital systems, Medicare Advantage management services organizations, skilled nursing facilities, pharmacies and pharmacists, physicians and physician groups, clinical laboratories and diagnostic companies, marketing companies and individual marketing agents, telemedicine companies and providers, and FDA-regulated manufacturers.
Not every fraud case is brought by the government. Insurers run their own investigations, and when a carrier concludes that a provider’s billing was not legitimate it sues to claw back what it paid and to stop paying anything further.
We defend clinics, treating physicians, and clinic owners against those claims. Automobile insurers including GEICO and State Farm have brought them against Florida providers by the dozen, typically pleading common law fraud, unjust enrichment, and the Florida Deceptive and Unfair Trade Practices Act, with damages extrapolated across years of paid claims and running to tens of millions of dollars.
These cases are won on the records, the billing data, and the corporate structure, not on the rhetoric in the complaint. We take apart the damages model, which is almost always extrapolated rather than counted. We litigate the difference between a billing dispute and a fraud scheme, which is where most of these complaints are weakest. And we defend the clinic’s ownership and licensure structure against the argument that it was never lawfully entitled to bill at all.
Our former federal prosecutors know how these cases are built, which is the difference between reacting to an investigation and getting in front of one. We have handled matters under the Anti-Kickback Statute, the health care fraud statute, the Stark Law, the False Claims Act, the Civil Monetary Penalty Law, and HIPAA, along with exclusion proceedings and RAC, MAC, and UPIC audits, from the first subpoena through jury trial and sentencing.
We have defended providers through each of the government’s recent waves of scrutiny: compounded medications, toxicology and urine drug testing, and genetic testing. We know what fact patterns triggered those investigations, because we were often looking at the same patterns from the other side of them.
The reason to hire a firm that has done this before is that the first two weeks are not spent explaining your own operations to your lawyer.
Capitation, risk adjustment, and encounter data. Capitation changes the standard overutilization analysis that federal fraud, waste, and abuse enforcement relies on in a fee-for-service setting, and that difference is often the defense.
Pharmacy owners, pharmacists in charge, prescribing physicians, marketing companies and agents, and telemedicine companies, in the government’s pursuit of compounded pain and scar cream distribution.
Consolidated billing under the Balanced Budget Act of 1997, the distinction between Part A and Part B covered stays, therapy billing, and the medical director requirements particular to the SNF setting.
Toxicology laboratories, interventional pain physicians, sober homes, and addiction treatment centers, in parallel civil and criminal investigations, including the screening and confirmation protocols the government’s theory usually depends on.
Laboratories, diagnostic and marketing companies, telemedicine companies, and physicians, against allegations of excessive or improper testing.
Anti-Kickback and Stark exposure in physician compensation and referral arrangements, internal investigations for boards and compliance committees, and voluntary disclosure under the HHS Self-Disclosure Protocol.
We act for the relator in select False Claims Act matters. Selective is the point: we file when the allegations, the damages, and the evidence are strong enough that the government has reason to take the case up, because these cases run for years and a weak one costs a relator more than it ever returns.
That means we have built the case the government is asked to intervene in, as well as defended against it. Few firms have run both sides, and it changes what we can tell a client about how a case is likely to go.
