Overlapping tracks against one practice
A single set of billing concerns can lead to a payer audit and an overpayment demand, and in more serious matters to a civil False Claims Act inquiry or a criminal referral, with licensing and program participation at stake as well. In New York, Medicaid matters may also involve the state's Office of the Medicaid Inspector General. These proceedings move on different timelines, and what you say or produce in one is usually available in the others. An audit that looks routine can be the visible part of a larger investigation. Defense work starts by figuring out which tracks are open and which are likely to follow.
Knowledge is the dividing line
Billing errors happen in every practice, and mistakes alone are not fraud. Criminal health care fraud requires that someone acted knowingly, and civil liability under the False Claims Act also turns on knowledge, which can reach reckless disregard of the truth but not simple carelessness. That is why the defense often focuses on what policies existed, what guidance was given, and who actually made coding and billing decisions. Records should be preserved as they are, and charts should never be amended after a request arrives in a way that could look like alteration. If staff are approached by investigators, they may speak with counsel first, and the practice should not discourage them from cooperating or tell them what to say.
Setting the first priorities
In an early meeting we review the requests you have received, the payers involved, and any deadlines attached to them. We discuss whether an internal review of a sample of claims makes sense, and whether that review should be done through counsel to protect it. We consider cash flow, since payment suspensions can strain a practice before any finding is made, and whether that suspension can be challenged. We also look at whether you, the practice, or individual staff need separate counsel. Then we decide how to respond to each request in a way that is consistent across all of them.
