Wound Care Fraud Defense
Strategic Defense for Healthcare Providers Targeted for Wound Care Fraud Under the Anti-Kickback Statute and False Claims Act
Wound Care Fraud Defense Team Lead
Former DOJ Attorney
Wound Care Fraud Defense Team Lead
Wound Care Fraud Defense Team Consultant
Former HHS-OIG Assistant Special Agent-in-Charge
Healthcare providers that bill Medicare, Medicaid, and other federal healthcare programs for wound care must strictly comply with all applicable statutory and regulatory requirements. Failure to do so can expose healthcare professionals and other providers to substantial penalties—including criminal penalties in some cases. The U.S. Department of Justice and its law enforcement partners are prioritizing healthcare fraud enforcement during the second Trump Administration, and they have been given the green light to aggressively pursue all providers suspected of defrauding the government and eroding public trust in the healthcare system.
A Defense Team with Deep Experience Representing Healthcare Organizations that Bill Federal Programs for Wound Care
Our firm represents healthcare professionals and other providers in federal investigations and enforcement proceedings involving the U.S. Department of Justice’s Healthcare Fraud Unit, Medicaid Fraud Control Units, the Federal Bureau of Investigation (FBI), U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), and other authorities. If your business or practice is facing allegations of wound care fraud—or any other form of federal healthcare fraud—we can help.
With a team that includes several former U.S. Department of Justice Prosecutors and federal agents, we understand how the government targets alleged fraud schemes involving patient care and healthcare benefit program billings, and we have an extensive track record of helping our healthcare clients avoid unnecessary consequences. To discuss your business’s or healthcare organization’s legal needs with a senior member of our team in confidence, contact us today.
Understanding What Constitutes “Wound Care Fraud”
So, what constitutes “wound care fraud” within the context of billing Medicare, Medicaid, and other federal healthcare programs?
Broadly, wound care fraud is simply healthcare fraud that involves billing Medicare, Medicaid, or another federal healthcare program (or, in some cases, a private insurance company) for ineligible services or items related to skin grafts and other sophisticated forms of treatment for severe wounds. Wound care specialists and other healthcare providers, durable medical equipment companies, medical supply companies, and other entities and professionals can all face federal scrutiny for submitting allegedly fraudulent claims for reimbursement related to complex wound care.
In many cases, federal fraud allegations targeting wound care relate specifically to billings submitted in relation to services and items provided to Medicaid and Medicare beneficiaries. This includes services and items provided by physicians, nurse practitioners, and others. All allegations of wound care fraud present substantial risks, and providers accused of submitting fraudulent claims to Medicare and other payors must be prepared to defend themselves by all means available.
Enforcement Risks Under the Anti-Kickback Statute and False Claims Act
Federal investigations and enforcement actions targeting alleged healthcare fraud schemes involving wound care frequently implicate both the federal Anti-Kickback Statute and the False Claims Act. With that said, they can involve allegations under the federal healthcare fraud statute (18 U.S.C. Section 1347) and a wide range of other federal laws as well. Some examples of potential enforcement risks in these cases include:
Submission of “False and Fraudulent” Claims for Wound Care
Many investigations arise out of the submission of alleged “false and fraudulent” claims for wound care. The False Claims Act prohibits the submission of these claims—including claims for reimbursement submitted under Medicare, Medicaid, and other federal healthcare programs. Wound care-related allegations that can expose healthcare providers to civil or criminal penalties under the False Claims Act include:
- Billing for medically unnecessary wound care services or medical supplies
- Billing for wound care provided by unlicensed medical professionals
- Improperly billing for diagnostic testing related to wound care
- Improperly billing for wound care provided to elderly patients or other Medicare beneficiaries
- Participating in wound care schemes designed to defraud Medicare or Medicaid
These are just examples. While billing for medically unnecessary wound care and the other billing-related violations listed above are all common allegations, targeted healthcare providers can face a wide range of other allegations as well.
Submission of “False and Fraudulent” Claims for Durable Medical Equipment
Along with “false and fraudulent” claims related to wound care, healthcare organizations and manufacturers can also face allegations involving claims related to the provision of durable medical equipment to Medicare beneficiaries and other patients. Here too, this includes providing items that are medically unnecessary. If auditors or federal authorities determine that a piece of durable medical equipment is medically unnecessary for a particular wound care patient, this can also trigger allegations of fraudulent billing under the False Claims Act.
Other Improper Billing Practices Involving Medicare Beneficiaries
Healthcare providers and other entities and individuals can face allegations related to other improper billing practices involving Medicare beneficiaries and other patients as well. This includes everything from submitting fraudulent billings for ambulance services to submitting fraudulent billings for pain medications or other controlled substances. In all cases, it is critical to have a clear and comprehensive understanding of the allegations at issue—as this is essential for building an informed, strategic, and cohesive defense.
Prescription Violations Subject to Drug Enforcement Administration (DEA) Oversight
Fraudulent billings for pain medications and other controlled substances can also lead to other serious (and potentially criminal) allegations. For example, along with the Anti-Kickback Statute and False Claims Act, these allegations can lead to enforcement action under the Controlled Substances Act (CSA) and a variety of other federal laws that cover prescription medications and prescribing practices. The government’s commitment to targeting fraudulent claims under Medicare and other federal healthcare programs is matched by its commitment to targeting prescription drug fraud, and the U.S. Department of Justice’s Healthcare Fraud Unit is aggressively targeting prescription-related enforcement as well.
Illegal Payment or Receipt of Patient Referral Fees
Referral fees paid out of Medicare and other program-reimbursed funds can constitute illegal kickbacks under the Anti-Kickback Statute if these transactions are not structured appropriately. As a result, taking the necessary steps to ensure that any payments do not constitute illegal kickbacks under federal law is a key aspect (among many others) of developing an effective wound care-related compliance program. In cases involving allegations of illegal kickbacks, all parties involved can face scrutiny (and penalties)—and this makes it critical to work with experienced counsel to develop and execute an effective defense strategy.
Responding to Investigations and Enforcement Actions Targeting Alleged Fraud
Whether you are facing allegations of intentionally billing for medically unnecessary wound care or you are facing allegations of failing to maintain a robust compliance program to ensure wound care-related billing compliance, time is of the essence. Our team is available to represent medical professionals, healthcare organizations, and other clients across the United States, and we can provide representation on an emergency basis when necessary.
Put our highly experienced team on your side
Dr. Nick Oberheiden
Founder
Attorney-at-Law
Lynette S. Byrd
Former DOJ Trial Attorney
Partner
Brian J. Kuester
Former U.S. Attorney
Hon. Kevin McCarthy
55th Speaker, U.S. House of Representatives (ret.)
Government Consultant
Mike Pompeo
Of Counsel
Former U.S. Secretary of State
John W. Sellers
Former Senior DOJ Trial Attorney
Linda Julin McNamara
Federal Appeals Attorney
Nicholas B. Johnson
Former Prosecutor
Roger Bach
Former Special Agent (DOJ)
Chris J. Quick
Former Special Agent (FBI & IRS-CI)
Michael S. Koslow
Former Supervisory Special Agent (DOD-OIG)
Ray Yuen
Former Supervisory Special Agent (FBI)
What Is “Wound Care Fraud”?
“Wound care fraud” is a type of healthcare fraud that involves improperly billing Medicare, Medicaid, or another payor for skin graft procedures or other complex forms of wound care. While wound fraud allegations can take many different forms, all allegations present substantial risks for targeted healthcare providers and professionals.
How Does the False Claims Act Apply to Allegations of Wound Care Fraud?
The False Claims Act prohibits healthcare providers from improperly billing Medicare, Medicaid, and other federal healthcare programs. If a provider improperly bills one of these programs for wound care items or services, this can trigger an investigation under the False Claims Act.
How Does the Anti-Kickback Statute Apply to Allegations of Wound Care Fraud?
The Anti-Kickback Statute prohibits healthcare providers from offering, soliciting, paying, or receiving referral fees paid using funds received from federal healthcare programs. If a physician or another provider improperly pays for the referral of a patient who needs wound care, this can trigger an investigation under the Anti-Kickback Statute.
Is Reliance on a Compliance Program a Defense to Wound Care Fraud Allegations?
Reliance on a compliance program can be an effective defense to wound care fraud allegations—provided that the compliance program is effective. If a provider’s compliance program is not effective (i.e., because it is out of date or overlooks key areas of compliance), then attempting to show reliance on the compliance program could do more harm than good.
Facing an enforcement action related to alleged healthcare fraud—including alleged wound care fraud—can present a variety of risks for targeted healthcare providers, hospice care providers, and other medical professionals and healthcare organizations. Along with the risk of facing civil or criminal penalties under the False Claims Act, targeted entities and organizations can also face loss of billing privileges, pre-payment review, and other penalties related to their ongoing participation in Medicare and other federal healthcare programs.
Schedule a Confidential Consultation with a Wound Care Fraud Defense Lawyer at Oberheiden P.C.
At Oberheiden P.C., we defend healthcare providers and other clients facing accusations of improperly billing federal healthcare programs for skin grafts and perpetrating healthcare fraud schemes involving wound care. To speak with a senior wound care fraud defense lawyer at our firm in confidence as soon as possible, call 888-680-1745 or tell us how we can get in touch online now.
