OIG Investigation Attorneys
Facing an OIG Investigation or Civil Investigative Demand? We Help Protect Your Career and Your Reputation
The U.S. Department of Health and Human Services Office of Inspector General (OIG) investigates suspected waste, fraud and abuse in Medicare, Medicaid and more than 100 other Department of Health and Human Services (HHS) programs. If you suspect you are the subject of an OIG investigation, or if you have received a Civil Investigative Demand or subpoena from the OIG, reach out to the lawyers at Hendershot Cowart P.C. immediately. Our healthcare fraud defense attorneys have more than a century of combined experience and have defended clients across Texas and the U.S. against fraud investigations.
Our goal in these matters is to provide immediate counsel and intervention, develop creative solutions to mitigate risks of criminal liability, keep investigations confidential, protect our clients’ reputations, and seek the most positive outcome possible.
On This Page:
- What Triggers an OIG Investigation?
- What Happens During an OIG Investigation?
- What Should I Do If I Am Contacted By An Investigator?
- What Are the Potential Consequences of an OIG Investigation?
- OIG’s Authority to Issue Exclusions from Federal Healthcare Programs
- How Can An Experienced OIG Attorney Help Me?
- Why Hendershot Cowart P.C.?
An investigation by the HHS-OIG typically focuses on allegations of fraud, waste, abuse, or misconduct within programs and agencies under the jurisdiction of the Department of Health and Human Services, including Medicare, Medicaid, and other federal healthcare programs.
OIG investigations can be set in motion in a few common ways, including:
- OIG analysts identify unusual practices or patterns and flag them for further review. Auditors are especially sensitive to red flags such as billing for services not provided, double billing, upcoming, and other potentially fraudulent actions.
- A whistleblower steps forward to file a formal report and initiate a qui-tam claim.
- Patients report providers or file formal complaints.
After analyzing the complaint or allegation, the OIG will decide to either dismiss the investigation, refer it to another organization, or begin an official investigation.
Once official, an OIG investigation is assigned to an agent or investigator who collects evidence and information through various methods. These fact-finding missions are conducted with a great deal of precision and a tremendous amount of foresight.
OIG agents are trained, credentialed, and sworn special agents (criminal investigators who are federal law enforcement officers), investigative attorneys, and administrative investigators. They know what they’re looking for, and they know how to get it.
Common investigative activities may encompass:
- RAC audits
- Civil Investigative Demands
- Qui-tam lawsuits initiated by whistleblowers with inside information about your business
- UPIC (Qlarant) audits
- Novitas records requests
If the investigation uncovers evidence of fraud or wrongdoing, the OIG investigator may recommend enforcement actions. This could involve civil or criminal charges against individuals or entities involved in the misconduct. Some cases may be referred to the U.S. Department of Justice for further action.
It is important to note that individuals and entities subject to OIG investigations have legal rights and protections throughout the process. Contact experienced legal counsel as soon as possible to protect those rights.
If an OIG investigator shows up at your door asking for an informal chat, politely but firmly insist that the interview not take place without your attorney present. Without an experienced healthcare fraud attorney by your side – even if you believe you’re in full compliance – you risk providing the OIG with information and evidence of inadvertent wrongdoing that can be used against you.
Requests for information may involve “formal” and less-formal approaches that – although presented as informal, genial, or due diligence endeavors – still pose risks and concerns for providers. These may include:
- Civil Investigative Demand (CID) – A form of administrative subpoena that allows federal agencies to gather documents and testimony in support of a healthcare fraud investigation. A CID may be sent to the subject of the investigation or to third parties that may have information related to the investigation.
- OIG subpoena – a request for documentary information that may include billing records, financial materials, marketing information, and e-mail communications. Unlike Civil Investigative Demands, OIG subpoenas do not generally demand interviews or interrogatory responses from providers.
- Requests for interviews or “chats” – In some cases, the OIG may contact healthcare providers and ask to speak with them. Often, investigators tend to present these talks as informal “chats” in which the providers they wish to speak with aren’t the target of an investigation. Providers shouldn’t be misled into thinking these “chats” don’t pose a risk. Seek legal counsel.
- An employee is approached by an agent – If an employee reports that an OIG investigator has approached them, or if investigators come to your facility, contact experienced counsel immediately. Never advise your employees to be untruthful, never encourage or request the destruction of documents or evidence, and do not attempt to prohibit your employees from talking to an investigator. You can, however, recommend your employee meet with counsel before the interview and offer representation during the interview.
- Unannounced visits – In some very severe cases, especially when providers ignore initial requests for information or subpoenas, the OIG may come knocking on their door to collect files and materials for their investigations. Though it is an extreme and not common action, it can and does happen. Providers should make copies of their documents, and immediately consult experienced attorneys.
It is an unfortunate fact that providers and suppliers who go without legal representation often end up ensnared in criminal cases involving healthcare fraud allegations. If you've been contacted by an investigating entity in any way, don't ignore it. Instead, obtain legal counsel as soon as possible.
OIG investigations are often conducted as parallel proceedings, meaning information obtained by investigators can be shared for the purposes of pursuing both civil and criminal action.
Criminal cases may lead to prosecution, resulting in charges brought against individuals or entities in federal court. Civil cases can lead to administrative actions, civil monetary penalties, exclusion from federal healthcare programs, and other enforcement actions.
Examples of OIG enforcement actions include:
- Civil monetary penalties (CMPs)
- Individual or entity Medicare or Medicaid exclusion
- Recoupment demands or restitution
- Assessment of risks for future fraud, which can result in additional oversite or the obligations to continue participation in federal healthcare programs
- Corporate Integrity Agreements (CIAs) reached through settlements that may lead to exclusion if breached
- Civil judgments or liens on property
- Criminal prosecution, potential incarceration in federal prison
Our goal as healthcare defense attorneys is to gauge the nature of the investigation, negotiate its direction and resolution when possible, and reduce risks for criminal action.
The OIG has the authority to issue exclusions for many different reasons. Sometimes, federal law requires that certain conduct results in a mandatory exclusion. In others, the OIG has some discretion in issuing permissive exclusions.
Examples of actions that result in mandatory exclusion include:
- Medicare or Medicaid fraud;
- Patient abuse/neglect; and
- Unlawful prescribing or dispensing of controlled substances at the felony level.
Mandatory exclusions typically call for a minimum exclusion period of five years (excepting second or subsequent offenses).
Permissive exclusions have no mandatory minimum period of exclusion for certain violations. Other violations, such as claims for excessive charges or unnecessary services, carry a one-year minimum exclusion. More serious violations, such as criminal convictions, have a minimum exclusion period of three years.
We tailor response plans to the unique circumstances of our clients; however, the general strategies we use to mitigate the impact of an investigation include:
- Determining if the Case Is Civil or Criminal: Information obtained through an OIG subpoena can be used as part of investigations into both civil and criminal liability. In recent years, the government has placed greater emphasis on parallel proceedings, which means documents collected via a subpoena can be shared between civil and criminal authorities, when appropriate. Most providers don’t know whether their OIG investigation is civil or criminal in nature. With an attorney on your side, you’ll have the opportunity to reach out to the investigators to learn why you are under investigation and whether your case is a civil or criminal complaint. Knowing this information will be essential in how you proceed with your defense.
- Opening Lines of Communication: By handling communications with authorities and establishing your credibility and cooperation with the government, we look to ease some of the immediate burdens created by subpoenas. Involving attorneys experienced in healthcare fraud defense can also help with extrapolating information about the investigation, exploring available strategies and options, and opening lines of communication for good faith negotiations and resolution.
- Easing Client’s Burden, Limiting Information Requests: Providing the government what it needs for its investigation is critical, as failing to respond may result in criminal contempt and additional consequences, in addition to harming your status in investigators’ eyes. Because such demands from the government can be broad and invasive, as well as costly and time-consuming to comply with, attorneys can assist providers when reaching compromises with the government to lessen the burdens created by subpoenas while still providing information relevant to the investigation.
- Protecting Client’s Rights, Preventing Mistakes: Providers are not without their rights during healthcare fraud investigations, nor are they immune from making grave mistakes. We know the rules and procedures by which investigators are bound, which lines they can and cannot cross, and the rights and options our clients have.
- Negotiation & Resolution: Negotiating a fair outcome is the objective in any healthcare fraud investigation, and especially so in those involving parallel proceedings. By tailoring strategies to the circumstances involved, and addressing all components of the investigation in negotiations, providers can take steps toward resolving all related matters, and ensuring any agreements bind other federal authorities. Negotiations may focus on avoiding criminal proceedings, reaching a fair settlement, and / or shielding providers from being excluded from government healthcare programs.
In addition, an attorney can help you conduct your own internal investigation. If the government made a mistake, you want to be able to provide them with proof of your compliance.
When faced with an OIG investigation, you need an attorney with extensive health care law experience. Our dedicated team has more than 100 years of collective experience and have represented clients in hundreds of OIG and other healthcare fraud investigations.
If you are facing an OIG investigation, reach out to the lawyers at Hendershot Cowart P.C. immediately. We understand how to defend you during OIG investigations, and we will work with you to protect your career and reputation throughout the investigation.
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