Compliance Plan & Preventing Health Care Fraud Allegations

Compliance Plan & Preventing Health Care Fraud Allegations

Health care fraud is committed when a person or organization defrauds the health care system in order to obtain funds or services. The Department of Justice (DOJ) estimates that health care fraud costs the United States tens of billions of dollars each year, with some estimates in excess of $100 billion a year.

This type of fraud can be carried out in a number of ways, and may involved complex and large-scale schemes. For example, a few of the most common health care fraud schemes involve improper billing, such as upcoming, billing for medical services not performed or not medically necessary, billing for medical equipment that was never provided, or accepting kickbacks in exchange for referrals.

The best practice is to take proactive measures to prevent ever being investigated for health care fraud. Implementing a Compliance Plan can help to prevent health care fraud investigations and ensuing allegations. Also, having a comprehensive compliance plan in place prior to being charged with health care fraud is a powerful defense against the allegations. It is important for any medical office to implement and enforce an office-wide Compliance Plan.

Even if you believe you are meticulous with your Medicare and Medicaid billing practices, it is important to have a Compliance Plan in place and to ensure your employees are properly trained to follow the plan. Further, it is important to have inter-office checks and balances to ensure compliance with all state and federal health care related laws.

The main purpose of a comprehensive Compliance Plan is to detect fraudulent activity in your practice. It also helps to ensure proper and legal billing practices, and when necessary, to serve as evidence to refute charges for health care fraud.

The Department of Health and Human Services’ Office of Inspector General (OIG) developed Compliance Plan Guidance for individual and small group physician practices, for hospitals, and for third-party medical billing companies. In its Compliance Plan Guidance for individual and small group physician practices, the OIG lists seven components that “provide a solid basis upon which a physician practice can create a voluntary compliance program:”

  • Conducting internal monitoring and auditing.
  • Implementing compliance and practice standards.
  • Designating a compliance officer or contact.
  • Conducting appropriate training and education.
  • Responding appropriately to detected offenses and developing corrective action.
  • Developing open lines of communication.
  • Enforcing disciplinary standards through well-publicized guidelines.

A comprehensive Compliance Plan is a necessary  component to any medical practice. It can also serve as evidence to combat health care fraud investigations.

Hire A Former Health Care Fraud Prosecutor To Defend You

As a former health care fraud prosecutor with the United States Attorney’s Office, Ashley D. Adams understands the government’s tactics and knows how to establish the best possible defense for your case.

Allegations of health care fraud can cause significant damage to your personal and professional reputation. Conviction of Medicare fraud, Medicaid fraud, or other health care fraud can result in harsh penalties, fines, even imprisonment. We have the experience and the resources to protect your rights and defend you against aggressive prosecution.

Contact us or call now (480) 219-1366 for a consultation.


The attorneys at Ashley D. Adams, PLC handles federal criminal cases throughout the United States, including Arizona, Oklahoma, Utah, and California.