Medical facilities, their employees, and in fact the entire medical industry is highly regulated, facing both state and federal scrutiny. That means that there are a lot of pitfalls for individuals who work in a medical facility, particularly regarding the legal system.
One of the most common problems facing this industry is the issue of healthcare fraud. This involves the unlawful billing of insurance companies (or Medicaid) for services that are either unnecessary or unused in order to be ‘reimbursed’ at higher costs. This is a serious problem for the government and tax payers – costing billions of dollars each year. The government and department of justice have made investigating suspicious billing practices a priority. The investigation usually begins by requesting an audit from the medical facility. Audits are triggered by medical practitioners who bill multiple times for one thing, or for something that usually does not accompany the kind of visit the patient had. For example, a red flag might be raised if a doctor orders a series of blood tests if a parent brought their child in for their routine vaccinations. This would be a violation of the Anti-Kick Back Statute – which is what the U.S. government uses most frequently in prosecuting healthcare fraud.
Audits should be taken seriously, but are not necessarily cause for alarm. Speaking with an attorney as soon as you receive the audit will help you organize your office, as well as understand your rights and duties under the law. Most of the time, attorneys will be able to help you formulate responses to the audit, including gathering patient records, correspondence with the insurer, and policies and procedures of the office. If you receive an audit, it will benefit you to seek out a good legal advocate as soon as possible. The FBI is the agency that is primarily responsible for investigating healthcare fraud, and the department of justice is responsible for prosecuting these crimes.
In the event the DOJ believes they have enough evidence to file and successfully prosecute a case, a settlement offer might be the most attractive choice for an accused fraudster. An attorney should be able to broker a fair and reasonable settlement, which will usually include fines and penalties, or even a program that incorporates additional training on compliance issues or a third party auditor to monitor future activities. An attorney experienced in healthcare fraud defense can advise you as to the best course of action based upon the facts and circumstances of your particular case.
Another major liability facing medical facilities today is medical malpractice. Most malpractice laws vary state by state. There are often ceilings on the amount of recovery a patient can get, and the procedures for suing hospitals and doctors for malpractice varies widely between jurisdictions. In New York, since 2013, the state has been ranked highest in the nation for payouts relating to medical malpractice lawsuits – topping over $711 million annually. Most medical facilities will keep an attorney on retainer in the event they are sued for medical malpractice. Often, they will also offer to represent the doctor who is implicated (if implicated) in the suit; however, this should be treated with caution. There is a chance that at some point there will be a conflict of interest for the attorney in representing both the hospital and the doctor. A doctor should always try to seek independent legal counsel in the event he or she becomes involved in a medical malpractice suit.