When Your Career Is on the Line Alongside Your Freedom

For physicians, healthcare providers and medical practice owners, an allegation of healthcare fraud can threaten far more than the outcome of a criminal investigation. It can jeopardize a professional license, the ability to participate in Medicare or Medicaid, relationships with hospitals and insurers, and the future of an established medical practice.

These consequences can arise through separate legal and administrative proceedings, sometimes involving different agencies with different rules and objectives.

Successfully addressing a criminal allegation does not necessarily resolve the professional and regulatory consequences.

At The Kreiss Law Firm, our experience in criminal defense and administrative law provides a coordinated approach to healthcare fraud matters, with attention to both the immediate allegations and their potential impact on a client’s professional future.

Healthcare Fraud Allegations Can Create Multiple Legal Problems

Healthcare fraud investigations frequently involve questions about billing practices, documentation, reimbursements and the medical necessity of services. Allegations may involve Medicare, Medicaid, private insurers or other healthcare benefit programs.

Common issues include:

• Billing for services allegedly not provided or not medically necessary
• Upcoding, unbundling or other disputed billing practices
• Allegations of false claims or inaccurate patient records
• Improper referrals, kickbacks or financial arrangements
• Prescription practices and controlled substance investigations
• Questions involving ownership, management or supervision of a healthcare practice

Not every billing error or compliance problem constitutes criminal fraud. However, when investigators suspect intentional misconduct, a regulatory or financial dispute can become a criminal investigation.

At the same time, licensing boards and other regulatory authorities may examine the underlying conduct independently of the criminal justice system.

The Criminal Case Is Only Part of the Picture

A physician or other licensed healthcare professional may be understandably focused on avoiding criminal charges, incarceration or a conviction.

But there are other important questions to consider.

Could I Lose My Professional License?

Healthcare fraud allegations can lead to investigations or disciplinary proceedings involving professional licensing authorities.

In Florida, certain criminal convictions and pleas can constitute grounds for professional discipline, and some qualifying offenses carry particularly serious licensing consequences.

The outcome of a criminal case, including the specific charges and terms of a negotiated resolution, may affect a professional’s ability to continue practicing.

Could I Be Excluded From Medicare or Medicaid?

Certain healthcare-related criminal convictions require exclusion from federal healthcare programs. Other conduct or licensing actions may provide grounds for discretionary exclusion.

For a healthcare provider or practice that depends on Medicare or Medicaid reimbursements, exclusion can have devastating financial and operational consequences.

Importantly, program exclusion is a separate issue from professional licensure. Maintaining a medical license does not necessarily mean a provider will remain eligible to participate in federal healthcare programs.

Could My Medical Practice Be Affected?

Even when an investigation focuses on an individual provider, its consequences may extend to the business.

An investigation or adverse finding can raise questions involving insurance relationships, credentialing, reimbursement, employment, ownership interests and the continued operation of a medical practice.

These concerns deserve attention before decisions are made in criminal or administrative proceedings.

Why a Coordinated Defense Matters

A Resolution in One Proceeding Can Create Consequences in Another

Consider a physician facing allegations of improper Medicare billing.

The immediate priority may be responding to investigators or defending against criminal charges. But the decisions made during that process may influence separate professional licensing proceedings or federal healthcare program participation.

A plea agreement, admission, settlement or other resolution may have consequences that are not immediately apparent when viewed solely through the lens of the criminal matter.

The goal should not simply be to resolve the first legal problem. It should be to understand what that resolution could mean for everything else.

The Kreiss Law Firm approaches overlapping criminal and administrative matters with consideration for how different proceedings interact. Our objective is to help clients make informed decisions that account for their legal exposure, professional responsibilities and long-term interests.

Representation Before Criminal Charges Are Filed

Healthcare fraud investigations do not always begin with an arrest or indictment.

A provider may first learn of a potential problem through a subpoena, records request, audit, agency inquiry or contact from government investigators.

This early stage can be especially important. How documents are produced, questions are answered and allegations are addressed may affect subsequent proceedings.

Seeking legal guidance before responding to investigators can help healthcare professionals better understand their rights, obligations and potential exposure.