Healthcare professionals are subject to some of the most stringent regulations in the country, being affected by both Federal and state laws. This can leave optometry centers open to multiple forms of liability, including criminal liability. Some of the most common crimes affecting optometrists and their facilities are crimes involving healthcare fraud, where they engage in fraudulent billing practices to receive unearned funds.
This kind of criminal behavior has proved very lucrative, and as a result the FBI and the Department of Justice have prioritized investigations into suspected healthcare fraud. Some of the most common practices that defendants are accused of are offering or receiving kickbacks, filing false claims with government health insurance programs, double billing or billing for services not rendered or not medically necessary, or maintaining financial relationships that are unlawful conflicts of interest. A good, experienced attorney should be kept on retainer to help you or your optometry center conduct regular internal investigations to find and correct problems before they come to the attention of the government. Attorneys can also help you design and implement compliance programs, procedures and training, and frequent education in the field of healthcare billing. Find an attorney that is well-versed in the federal, state and regulatory laws that affect your practice.
A major red flag for the FBI is the double billing, or billing for services that were not rendered (or are not typically rendered for the type of appointment). You will know when an investigation is to begin if you receive an audit from a Zone Program Integrity Contractor (or ZPIC). They are responsible for identifying suspected fraud. In the event you receive one of these audits, you should contact a competent healthcare defense attorney as soon as possible. They will help you both prepare and respond to an audit, as well as be able to advise you of your rights and obligations under the current law. They will also help you determine which documents you will need to send in to the auditor, as well as identify privileged communications to avoid future malpractice claims. Always respond promptly to an auditor. Further, once an audit has begun, make sure you document everything and do not destroy any evidence, even if done in regular practice of the business.
If you are the subject of an investigation concerning some form of healthcare fraud, seek out an attorney who is experienced in this field of white collar defense. The penalties for such behavior can be steep. In 2008, a licensed optometrist was sentenced to 36 months in prison, with 3 years of supervised release for executing a healthcare fraud scheme. He was also ordered to pay $1 million in restitution, and was fined $100,000.00. These crimes are taken and prosecuted very seriously by the government, and they will not prosecute a case unless they can be sure of a conviction. An attorney can also help you become the target of only a civil investigation, rather than criminal. If the coding errors occurred because of mistake or human error, rather than with an intent to defraud the government, you may only incur civil liability (which means fines) rather than criminal liability (which usually means jail time).
An attorney will also have access to powers of the court to subpoena documents and elicit testimony from witnesses, employees and even patients. Further, they will know expert witnesses to validate your defense, as well as be better prepared to question and cross-examine any expert witnesses the prosecution may call during trial. Overall, a strong defense attorney will be able to help you from the moment you are a target of an investigation, up to the last question in a jury trial. It is best to seek out their guidance and advice as soon as you’re able.