Fraudulent Physician Certifications

Healthcare fraud is a sore subject with the federal government. In their zeal to prosecute those who are defrauding the government through false or fraudulent claims, prosecutors in Michigan often go after physicians and other health care providers who have done nothing wrong or made unintentional errors.

Physicians accused of providing fraudulent certifications may need to take special care. With the potential for costly civil and criminal penalties, false certification issues could cause trouble with insurance providers and licensure.

Those facing fraudulent certification allegations are advised to consult a Michigan fraudulent physician certifications lawyer. A knowledgeable healthcare fraud attorney who understands how to defend against fraudulent certification charges can provide valuable information and representation to help reach a positive outcome in the case.

Federal law set forth in 42 U.S.C. §1395y specifies that Medicare and Medicaid programs are only supposed to pay for medical treatment and services deemed to be "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." Claim forms also often require health care providers to certify that services, equipment, treatment, and other prescribed items are medically necessary.

As a fraudulent physician certifications attorney in Michigan could further explain, what is classified as medically necessary may vary according to different standards. In many situations, a service is considered reasonable and necessary if it meets with accepted standards in the medical practice of the community and research information. The Centers for Medicare and Medicaid work with both National Coverage Determinations and Local Coverage Determinations to ascertain whether a service is reasonable and necessary.

Both the federal government and individuals seeking to "blow the whistle" on practices they perceive to be fraudulent may bring an action under the federal False Claims Act. This act provides penalties when someone makes a fraudulent claim for payment from the government or makes a false statement to support a fraudulent claim.

False Claims Act violations may be alleged against physicians if someone believes the doctor or someone in the doctor's office has submitted fraudulent certifications to support a claim for benefits under Medicare, Medicaid, Tricare, or another federal medical program. Those found to have violated the act may be required to pay treble damages and pay additional fines of up to $10,000 under 31 U.S.C. §3729. Consulting a knowledgeable fraud attorney could help you learn more about the False Claims Act.

In many situations where false claims violations are alleged against physicians, courts have held that the claim must be based on an objectively verifiable falsehood. Simply put, a mere difference of opinion regarding medical necessity would not be enough to make a claim false by this metric. Instead, a physician must have certified a fact that was objectively and demonstrably false.

Moreover, false claims based on negligence or mistakes may also not give rise to liability under the False Claims Act. Therefore, when defending against allegations of physician certification fraud, it is important to remember that the prosecuting party must demonstrate that false information was knowingly presented. A fraudulent physician certifications lawyer in Michigan could work to discover and present evidence which demonstrates either that alleged falsehoods are not objectively false or that any false statement was made unintentionally.

While it is quite possible to defend against charges of fraudulent physician certifications successfully, it is also wise to take allegations seriously and start preparing as soon as possible. A knowledgeable Michigan fraudulent physician certifications lawyer can help at all stages of the process, from providing advice to advocating on your behalf in both formal and informal proceedings and negotiations.

Healthcare fraud can open a provider up to criminal and civil liability, and cases may be prosecuted by either the federal government or the Health Care Fraud Division of the Michigan Attorney General's office. If you are facing allegations involving fraudulent physician certifications or any other form of fraud, you deserve to have experienced legal advocates defending your rights and interests. To learn more, call today to schedule a consultation.