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Healthcare Fraud

Contra Costa County Healthcare Fraud Lawyer

Daniel Horowitz: Leading Trial Lawyer in Healthcare Fraud

Daniel Horowitz is recognized as one of the nation’s top trial lawyers, with extensive experience in litigating healthcare fraud cases in both state and federal courts. 

The Horowitz medical legal team handles fraud cases nationwide, maintaining a strong presence through affiliated attorneys in New York, California, Washington, Washington D.C., and Texas. A key member of our defense team is Dr. Mark Ravis, a physician and lawyer, who brings invaluable expertise to our practice.

Our lawyers are often asked to explain fraud in terms of the healthcare profession.  This is an important question because healthcare fraud is different from typical financial fraud.  Financial crimes are generally schemes like the FTX cryptocurrency fraudulent scheme.  Healthcare crimes are called fraud but they often involve violations of rules that are necessarily evident.  The Stark Law, Stark Law ancillary exceptions, the AKS (anti kickback law), the Federal Exclusion Statute, even worker's compensation fraud are often creatures of statute and are not inherently evil acts.  Therefore the definition of fraud in healthcare often lacks the concept of planning or outright theft that is so common in financial frauds.

Healthcare fraud cases carry enormous monetary and criminal penalties.  It is important to obtain legal assistance at the earliest opportunity in order to mitigate your potential criminal and monetary exposure.

What is the Physician Self-Referral Law (42 U.S.C. § 1395nn) - “The Stark Law”

The Physician Self-Referral Law is commonly referred to as the (Pete) “Stark law”.  It prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid. When you see a term such as Medicare fraud attorney it often refers to allegations of Stark violations but not necessarily. The Code of Federal Regulations has a myriad of rules that a practitioner, hospital or medical practice can violate. Generally the violations result in a compensation dispute but at times there is Stark law spillover. Stark law violations are limited to “designated health services” and the referral has to be from entities with which the physician or an immediate family member has a financial relationship.  And then there are many exceptions.

Understanding the Physician Self-Referral Statute (Stark Law)

Physicians setting up related medical businesses, inter-related medical practices, or concierge practices with in-house physical therapy need to be aware of the physician self-referral statute. In California, many of these “Stark Law” violations can also be charged as insurance fraud under Penal Code section 550 when the payor is not the United States government.

Medicare Fraud and Stark Law Violations

When you see terms like “Medicare fraud attorney,” it often refers to allegations of Stark Law violations, but not exclusively. The Code of Federal Regulations contains numerous rules that practitioners, hospitals, or medical practices can violate. Generally, these violations result in compensation disputes, but sometimes there is Stark Law spillover. Stark Law violations are limited to “designated health services,” and the referral must be from entities with which the physician or an immediate family member has a financial relationship3. There are many exceptions to these rules, making it crucial to understand the specifics of each case.

Read Daniel's Blog Post on Why We Track Large Hospital Stark Cases

Physicians: Beware of Business Relationships with Promoters

Physicians should exercise caution when entering business relationships with promoters who may seek to use your license to spearhead ventures they claim are lawful and compliant with the Stark Law. When evaluating a business proposal or scheme, remember that financial relationships include both ownership/investment interests and compensation arrangements, unless an exception applies.

For example, a cancer clinic that owns state-of-the-art imaging equipment must be very careful and make full disclosure before referring patients to their wholly or partially owned facility, or one they receive referral fees from. This vigilance is crucial to avoid potential Stark Law violations and ensure compliance with all regulations.

PHYSICIANS BEWARE - DON'T LEND YOUR NAME

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hey Follow Your Money – We Can Follow Their Money

Insurance companies provide funding to prosecutorsSpecial taxes on employers also support fraud investigations. This means there is a financial and emotional incentive for fraud prosecutors to file charges. The insurance companies become “crime fighting” partners to the district attorney white collar crime units. Medical practice management has many grey areas. Few white collar prosecutors have sufficient medical/medical billing/delegation of medical duty background to accurately assess the legitimacy of your conduct.

Many seminars are funded by insurance companies and some local prosecutors are “honored” with the opportunity to speak at those seminars to promote their careers.   Prosecutorial objectivity is often compromised.

BIG PROFITS – False Claims Act, 31 U.S.C. 3729 (FCA)

The False Claims Act, 31 U.S.C. 3729 (FCA), is a federal civil fraud statute. The FCA allows healthcare fraud, medicare fraud, and false claim lawsuits to be filed by professional litigators, disgruntled former employees and others.  They are called “relators” and they sue on behalf of a “defrauded” governmental entity.   The incentive is a percentage of the final recovery.

The government can also file its own civil fraud claim.    

Many times, a criminal case will follow shortly after the filing of one of these cases.  Sometimes the False Claims Act filing with be parasitic and follow the filing of criminal charges.  This is yet another expense that burdens a defendant.  Fortunately, some insurance policies will defend against these claims.

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  • Top 100 Trial Lawyers by The National Trial Lawyers
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  • United States Court of Appeals Ninth Circuit
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The Laws are Vague

The anti-fraud laws seem clear.  Don’t commit fraud.  Don’t submit false billings !  Don’t bill for services that you didn’t perform ! What could be easier ?

You’re honest, so you have no worries …………………………..?      Right ?

Maybe.  If you regularly bill 99241-99245, you know that it is not always clear which code applies.  If you consistently bill the grey areas in “your favor”, your computer score may be “skewed”.  The little “UPCODING” / “BILLING FRAUD” light goes on in SIU Headquarters.  You may not be upcoding but to the computer, all doctors of your type or class, are the same.

Geographic issues come into play.  If you are in a high quality of care community, you may make more specialist referrals, order more tests and spot more problems than if you are understaffed and lack quality diagnostic equipment. You may be seen to be over utilizing and hence over billing.    On the other hand, in an underserved area that lacks resources, a physician may compensate by spending more time with patients.  Simple visits may genuinely justify a high billing code.  But the computer may flag you for upcoding.  If you are rushed and your clinical documentation is “light”, you may have trouble defending your legitimate billings.

Areas such as Los Angeles have their own billing fraud focus.   Investigators focus on cosmetic treatments hiding as medical treatments. That happens a lot but the insurance company investigative net is wide and at times, indiscriminate.  Honest practitioners can get caught the same way Dolphins end up in Tuna nets.

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Client Testimonials

Contra Costa County Location - National Reputation for Excellence
    “What impressed me most was his unwavering dedication to achieving the best possible outcome for me.”
    I cannot express enough gratitude for the outstanding legal services provided by Daniel Horowitz. He not only possesses an in-depth understanding of the law but also demonstrated a genuine commitment to me. He took the time to listen attentively to my concerns, providing clear and concise explanations of the legal processes involved in my case. He made me feel heard and supported during this tumultuous time. What impressed me most was his unwavering dedication to achieving the best possible outcome for me. The attention to detail and strategic approach to my case were evident at every stage. I am eternally grateful towards Daniel for what he has done for me and I wholeheartedly recommend his services to anyone seeking legal representation. Thank you Dan
    Kento T.
    “Despite his kindness, I have never once doubted his ability to provide me with THE BEST representation in court.”
    He is approachable but serious. Mr. Horowitz is the perfect balance of what someone wants in a lawyer. Not only is he approachable enough to gain and value your trust, but he's a bulldog in the courtroom. Despite his kindness, I have never once doubted his ability to provide me with THE BEST representation in court. I'm so thankful to have found a lawyer capable of such a delicate balancing act.
    Molly A.
    “I would highly recommend the Law Office Of Daniel Horowitz.”
    My experience with Dan was great. I appreciate the knowledge Dan has and the professionalism they exhibit. I would highly recommend the Law Office Of Daniel Horowitz. My family and I are truly grateful we worked with him.
    Brandon D.
    “He believed in me and listened to what I had to say.”
    I can not say enough about Mr. Horowitz and his staff. Brook was amazing to myself and my family. My case was very unique. He believed in me and listened to what I had to say. I highly recommend him and his staff. Yvett Bline
    Yvett Bline

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