Dr. M Blatstein's Blog

When Was Your “Last Medical Billing Self-Audit,” The DOJ May Be Watching You

When Was Your “Last Medical Billing Audit” of Policies, and Procedures? Don’t Let the DOJ Suprise You One Morning – Learn the Do’s and Dont’s

No matter where you are in the healthcare community, ultimately we all want the best for our patients and have spent countless years of our lives in school(s), studying, and improving our skills. We also intuitively understand that “life” will sometimes be frustrating as we juggle our business, practice, patients, and family responsibilities. At the same time, nobody ever expects to get a visit from The Department of Justice (DOJ) – until you do.

COVID-19 Has Kept The DOJ White-Collar Task Force – Busy!

COVID-19 DOJ HEALTHCARE FRAUD UNIT

Nationally, Healthcare spending is approaching $2-3 Trillion. The DOJ has created a White-Collar Task Force Targeting all aspects of Fraud in the Healthcare Space. In 1985, The National Heath Care Anti-Fraud Association was formed and recently released its updated Fraud Briefs:

The NHCAA Fraud Brief covers a broad overview of complex issues.

We never entered this field to commit fraud, but with COVID, for example, Telemedicine has exploded. And yet Post-COVID, for some (if not all?) specialties, are these Telemedicine visits routinely still available and billable? As the laws change, are we keeping up with everyone, or are we depending (for some of us) on the medical groups to which we’re members, to make these decisions for (and notify) us, as well as update our billing software? Where does our responsibility start, and end?

PREPARATION.

For those who have had that unfortunate early ‘am’ FBI visit, and ‘Did not know where to turn or what to do – Now You Do.

The DOJ is an Equal Opportunity Enforcement Agency. Should you be a multi-specialty medical practice, NP, MD, DO another specialty, or in any other industry, in general; established self-audits are much more agreeable than the 6 am knock at your front door, followed by a visit to your office – with Warrants in hand.

CORPORATE MALFEASANCE.

U.S. Attorney General Merrick B. Garland and Deputy Attorney General Lisa O. Monaco have increased their corporate and white-collar enforcement trend through the Department of Justice FY 2023- 2024, by prioritizing the investigation and prosecution of financial and Corporate Malfeasance – This Includes Healthcare.

The DOJ wants Corporations to disclose all relevant, non-privileged facts about individual misconduct. In essence, the DOJ strongly recommends that Corporations (including the small ones, albeit to a lesser degree), self-police their policies, procedures, and employees, notifying them should they find something amiss – before they show up at your front door.

The October 2021 Memorandum on Evaluating a Corporation’s History of Misconduct: the corporation must identify all individuals involved in, or responsible for the misconduct at issue, regardless of their position, status, or seniority, and provide to the Department all nonprivileged information relating to that misconduct.

Also being investigated are CLINICAL LABORATORIES, INDIVIDUALS, INSURERS WHO “KNOWINGLY SUBMIT or FAILED TO CORRECT or CAUSED THE SUBMISSION OF INACCURATE INFORMATION, KICKBACKS, OPIOIDS (Self-Use, Distribution or Manufacture, etc), OVERPAYMENTS, PPP LOAN FRAUD, SUBSTANDARD CARE, and UPCODING, to mention a few.

As in Malpractice, the “dumb” (doctor, nurse, or executive) defense doesn’t work with the feds. If you hear rumors or have received the Target letter, the DOJ case Is 97%+ Complete. On top of that, they have a 98% Conviction Rate and Very Deep Financial Pockets with which to Prosecute – so you have work to do.

THE DOJ IS SERIOUS, HERE’S A PARTIAL FY 2022-2023

The DOJ collected $2.2 B, Just Through False Claims Act FY 2022

Deputy Assistant Attorney General Lisa H. Miller Delivers Remarks at the American Bar Association’s 33rd Annual National Institute on Health Care Fraud, May 4, 2023, Speech,

  • 05.23.2022 MEDICARE ADVANTAGE OVERPAYMENTS

The Dept. of Justice (DOJ) White Collar Fraud Section leads the Health Care Fraud Strike Force, which maintains 15 strike forces operating in 24 federal districts and has charged more than 4,200 defendants who have collectively billed the Medicare program for nearly $19 billion.

The Strike Force is a collaborative effort of The FBI, HHS-OIG, CPI/CMS, the U.S. Postal Inspection Service, U.S. Postal Service Office of the Inspector General, Department of Defense Office of Inspector General, Department of the Interior Office of the Inspector General; Department of Labor Office of the Inspector General; Food and Drug Administration Office of Criminal Investigations; Homeland Security Investigations; U.S. Department of Veterans Affairs Office of the Inspector General; and other federal and local law enforcement agencies.

This is quite an impressive group of agencies and just one more reason to go back to basics and self-audit your billing policies, and practices.

For transparency, in 2006, due to a white-collar crime, I too was convicted of a felony. While there was never any issue regarding the quality of patient care provided, I took responsibility for my actions and that of my practice. Later, with work and the support of colleagues, my license to practice was restored in full – in 2010. I bring this up because getting a Felony – was “Never on My Radar.”

While I am grateful for all my support, I was especially appreciative when my license was reinstated. There was a moment years later when I realized how UNPREPARED I was for the entire process of a Legal Defense and Unanswered Expectations of Prison Started With Day 1.

BELOW.

Once you hear rumors that they are watching you, their case is mostly complete, and you need an attorney who practices White-Collar Federal Criminal Defense in Federal Court and who handles cases similar to yours—start interviewing.

There are many things that you can “do” to help yourself before you are Indicted, before your Guilty Plea Hearing, or before your Presentence Interview, all of which are usually not part of a traditional legal defense.

MY MISSION.

Having had a former prosecutor as my attorney, I still found myself  UNPREPARED for the entire, process of a Legal Defense along with having no idea of what I should expect once I entered Federal Prison. It was like being dropped into a foreign country (or Planet), and not knowing what to expect, the language, or the customs of appropriate behavior.

I needed to find a way to provide answers to the many obstacles I encountered – so that others would be prepared, where I was unprepared.

  • My goal is to share my experiences so that should you be one of the unlucky few, you know that – This Is Not The End Of The World. This is temporary, and you will be prepared so that you will know what to, and not to do once inside.
  • In addition to working toward an earlier release date (which in Government, there’s nothing that anyone can guarantee), this will build confidence before you enter federal prison, which in turn will also be a stress reliever to your family. Transitioning away from patient care, to that end I founded PHYSICIAN PRESENTENCE REPORT SERVICE LLC,

In my way I am still caring for people, just not through the traditional healthcare system, but rather By Changing the Lives of Individuals and their Families, as they face this Life-Altering Event.

This article also appeared on LinkedIn