Category Archives: Healthcare Fraud
Physician Compensation Based On Productivity: Navigating Federal Enforcement Risks
A physician may receive a productivity bonus after performing more procedures, expanding clinic hours, or taking on a heavier patient load. Years later, federal investigators may place those payments beside referral data and argue that the compensation rewarded business sent elsewhere in the health system rather than the physician’s own work. The formula becomes… Read More »
The Criminalization Of Medical Judgment: When Disagreements Become Federal Charges
A physician may believe a treatment is medically necessary while an insurer, expert reviewer, or federal investigator reaches a different conclusion. That disagreement can begin with dosage, treatment frequency, testing, therapy duration, or the use of a particular procedure. In a criminal investigation, however, prosecutors may try to turn the disagreement itself into evidence… Read More »
Telehealth Marketing Arrangements: When Lead Generation Becomes A Criminal Scheme
A telehealth company may begin with a marketing contract designed to bring patients into a virtual care network. Leads arrive through online advertising, outbound calls, health questionnaires, or outside vendors. Physicians are then asked to evaluate patients remotely and decide whether treatment, testing, equipment, or another service is appropriate. That structure can become dangerous… Read More »
Home Health Certification Fraud: Risks For Physicians Signing Off On Care Plans
A physician may receive a home health certification after a hospital discharge, office visit, or referral from an agency already involved with the patient. The paperwork may include diagnoses, nursing assessments, therapy recommendations, and a proposed plan of care assembled by people outside the physician’s practice. Signing that certification may seem administrative. During a… Read More »
Clinical Trial Billing Fraud: When Research And Reimbursement Overlap
A hospital may treat a patient while also enrolling that person in a clinical trial. Physicians order scans, laboratory work, medications, and follow-up visits as care continues. Research sponsors may pay some expenses, while Medicare or a private insurer remains responsible for others. A classification made at that intersection can later become the basis… Read More »
“Medical Director” Agreements Under Scrutiny: When Compensation Structures Trigger Criminal Charges
A medical director agreement can begin as a practical arrangement. A physician agrees to oversee clinical standards, review policies, participate in quality meetings, or provide administrative leadership. Compensation follows. Years later, federal investigators may compare those payments with referral activity and argue that the title concealed something very different: money paid to secure federally… Read More »
Criminal Liability Without Intent? How Federal Prosecutors Prove “Knowledge” In Healthcare Cases
A healthcare investigation may begin with disputed claims, questionable referrals, or records that appear inconsistent with what was billed. The harder question for prosecutors is often what a physician, executive, owner, or administrator actually knew when those decisions were made. That proof rarely comes from a single admission. Investigators build it from emails, meeting… Read More »
Fair Market Value Opinions Under Attack: Defending Physician Compensation Arrangements
Hospitals and medical groups may offer higher compensation to recruit a difficult-to-find specialist, secure call coverage, or fill a leadership role. Those payments can serve legitimate operational needs. Years later, investigators may revisit the arrangement and question whether the valuation supporting it reflected the physician’s work or the referrals the organization expected to receive…. Read More »
Laboratory Billing Practices In Addiction Treatment Programs
A treatment center may collect urine specimens as part of a patient’s recovery plan. Months or years later, federal investigators can use those same specimens to build a criminal case around testing frequency, laboratory relationships, toxicology claims, and payments connected to patient referrals. What began as a clinical process can become the foundation for… Read More »
Healthcare Executives And Non-Physicians Face Rising Criminal Exposure
Federal healthcare fraud cases no longer stop with the physician whose name appears on a claim. Prosecutors are looking further into the business operations of medical organizations, where compensation plans are approved, billing systems are implemented, compliance concerns are resolved, and revenue expectations are enforced. Executives who once viewed themselves as removed from patient… Read More »
