Would you know if you were the target of a health care fraud investigation?

Would you know if you were the target of a health care fraud investigation?

Find out if you are a health care fraud target.

Would you even know if you were the target of a healthcare fraud investigation?
Discover whether you are a healthcare fraud investigation target.



Healthcare Fraud

Are You the Target of a Healthcare Fraud Investigation?

Would You Even Know?

Reimbursement Denials May Be Your First Clue That Your Files Have Been Flagged!

If Your Files Have Been Flagged, Brace Yourself –A Storm Is Brewing!

Dear Doctor:

Healthcare providers across the country are being targeted for healthcare fraud investigations. Many of those providers are clueless of this fact!

Are your own actions causing you to be targeted?

Do you do one or more of the following?

You accept what the insurance carrier offers, without question.

You work with 3rd- party liability carriers and accept what your patients give you once they receive settlement, and accept your patient’s account of settlement negotiations.

Your patient retains an attorney to handle a 3rd-party liability claim, and you accept the attorney’s offer of settlement without question.

You work consistently with a limited number of external providers (e.g., physicians, surgeons, neurologists, etc.).

You don’t bother to read the Explanations of Benefits (“EOBs”) in which the insurance carrier identifies the reasons for denial.

You don’t bother to read peer reviewers’ reports.

You don’t bother to respond to the peer reviewers’ reports, considering them merely a nuisance and cost of doing business with insurance carriers.

You either don’t bother to read, or don’t receive, Controverting Affidavits in which both reasons for denial are reported and aberrant practices are alleged.

You don’t bother to respond to the Controverting Affidavits in which reasons for denial are reported, considering them merely a nuisance and cost of doing business.

You don’t bother to respond to Controverting Affidavits in which aberrant practices (e.g., unbundling of services, medically unnecessary services, medically unnecessary referrals, etc.) are alleged, because you either consider such allegations harmless or you have neither the time nor ability to provide a response challenging such allegations.

If the answer is yes, then you need to take action immediately.

While you can rationalize to yourself that these issues are just the cost of doing business, a nuisance and can be ignored, the consequences can be disastrous.

By not sticking up for yourself you are looking an awful lot like someone who is afraid to challenge the system…maybe because of guilt…at least that is what the carriers want to believe.

Here are some real life examples

Example #1

Practice:

Medical neurologist billing for neurological evaluations, as well as electrodiagnostic services, when those services were billed by a physician located hundreds of miles away from the lay-technicians the neurologist employed, at the very time his lay-technicians were performing those services.

Consequence:

Providers, to include those providers splitting fees with the neurologist, and technicians were convicted of felonies.

Example #2

Practice:

Chiropractor convinced husband and wife that the chiropractor had cured the HIV+ positive husband, and that the husband and wife, who had obtained permission from their church-council to engage in protected-sex, a practice prohibited by that community, could engage in unprotected sex.� The wife and baby subsequently contracted HIV.

Consequence:

Suspension of license.

Example #3

Practice:

Physician allowing a lay-individual to direct physician’s treatment, etc.

Consequence:

Loss of license.

What can I do?

What are some of the ways in which you may salvage your practice, license, and freedom if you have become the target of a healthcare fraud investigation?� Here are a few examples:

Develop a healthcare compliance program. Do not make the mistake of believing that a sham compliance program will suffice. You are better off having no compliance program than merely using one for window-dressing. The false sense-of-security often proves disastrous!

Develop an audit-response program that effectively addresses deficiencies, both noted and alleged.

Develop a policy for refunds of monies paid in error, when such errors are noted during internal audits.

Develop an effective auditing process, assessing medical necessity and billing issues.

Meet with SIU agents who may have “flagged” your files to identify specific areas of concern.

Develop a Hotline to address issues of concern coming from employees, patients, insurance adjusters, etc.

It may be possible to enter into a Corporate Integrity Agreement between the targeted-provider and investigators.

Retain an attorney knowledgeable in healthcare law. Do not trust your fate to an attorney inexperienced in this arena. Rest assured, the insurance carriers will not!



I have seen the exodus of hordes of providers due the insurance industry’s stranglehold on the healthcare industry, and I have taught literally thousands of providers to fight back.

What should you do now?

If you either know or suspect that you are the target of a healthcare fraud investigation, do not delay seeking a resolution! It is likely that your problem is compounded with each passing day.

If you would like to know whether you either are a target or likely to become the target of a healthcare fraud investigation, I can assist you in analyzing your current practices.

Thomas Rhudy
www.thomasrhudy.com