Last Updated on: 28th July 2023, 07:23 pm

The complexity of running a nursing home or hospital makes it likely that these entities will need skilled legal representation. Often, nursing homes and hospitals will be targeted for criminal or civil investigations, and in some cases, audits can become a nuisance that keeps the nursing home or hospital from being as efficient as possible. Because these types of medical providers operate with high volume, see many patients, and deal closely with Medicare and Medicaid, they are targets for investigations from federal agents. Likewise, nursing homes and hospitals are often seen as ideal defendants because of their deep pockets, making them likely targets for lawsuits. The key for hospitals and nursing homes alike is to have a good legal team on board to help during audits, investigations, prosecution, and perhaps more importantly, during the planning phase so they can avoid these messy situations altogether.

Defending against claims of overpayment
The current medical climate is rife with competition. Likewise, government regulation has been stepped up because of the recent focus on health insurance reform. What this means, then, is that those in charge of Medicare and Medicaid are highly incentivized to go after any entity thought to be overcharging patients. This can even have an impact on those nursing homes and hospitals that are playing by the rules. The increased number of audits for overpayment have put a burden on medical providers and made it much more difficult to provide quality medical care to people on Medicaid, Medicare, and even private insurance.

Audits typically come about because a hospital or nursing home’s claims triggered the automatic red flag of a computer system. Once an audit begins, however, the investigators are free to look through anything they want. It’s an invasive process that often takes months and drains resources. These overpayment audits can lead to civil penalties and criminal prosecution in some cases. These dire consequences underscore the importance of good representation for those nursing homes and hospitals accused of wrongdoing.

Understanding “medically necessary” services
Nursing homes and hospitals are often forced to deal with contentions that they’ve provided a medically unnecessary service. During the context of treatment, when a doctor is trying to alleviate pain or otherwise help a patient, the lines that define medical necessity can be blurred. After the fact, some investigators will attempt to make the medical providers action seem more nefarious than it is. In these cases, it is critical to demonstrate that the hospital or nursing home followed all of the insurance company’s guidelines for determining whether something was medically necessary. The best defense is a demonstration that you played by the rules as defined by the insurance provider itself.

Improper coding and billing
Many problems faced by hospitals and nursing homes arise from allegations of improper coding or billing. Given the complexity of medical billing, mistakes are bound to happen at some point. There are stark differences between the intentional acts of fraud and the accidental billing issues that might happen because of a new employee put in the wrong code. Good lawyers are able to demonstrate that even though problems might have arisen, those problems were more the result of negligence than intentional malfeasance. Good lawyers can demonstrate that the hospital or nursing home took all proper precautions to ensure that its billing and coding systems were in compliance.

Who brings allegations against nursing homes and hospitals?
An investigation can be started by a host of different agencies. State and federal agencies alike have the ability to start their own investigations. Allegations or suspicion of fraud is one of the top reasons why the authorities will get involved. Likewise, if there are any allegations of drug misuse, agents of the Drug Enforcement Agency(DEA) will be much more likely to get involved. Likewise, agencies dealing with environmental violations can have a say in the proceedings if a hospital or nursing home is accused of improperly disposing of its waste. Given the wide number of different law enforcement agencies with an interest in hospitals and nursing homes, it is critical for you to have proper representation.

Compliance and the art of prevention
Going through an investigation is expensive, risky, and cumbersome. The best option is to avoid allegations altogether. While no compliance program can completely eliminate the risk of an investigation, good compliance can make a difference over the long run. Good compliance programs have several mechanisms that look to prevent, detect, and even correct violations of state and federal law. Good compliance programs are not designed to make life difficult for hospital and nursing home administrators, but rather, to protect them from potential disaster.

One of the upsides of having a good compliance program is that you’ll earn significant good will with law enforcement agencies if you happen to run afoul of the law. If you can show that your hospital or nursing home was taking steps to remain in compliance, then you’ll avoid claims of intentional wrongdoing. You may even receive more lenient treatment because of your program.

Keeping proper records
Good lawyers will tell you that it’s critical to keep strong records. If you happen to be audited or investigated, you’ll want a full accounting of what’s happened in your hospital or nursing home over the last few months or even years. Good lawyers can help you understand how record keeping affects your liability and how it can save you from potential trouble if law enforcement happens to get involved.

Good lawyers help with all parts of the process. From helping to prepare compliance programs to dealing with the uncertainty of an audit or investigation, a solid lawyer can bring peace of mind. Top-notch representation will ensure that allegations of overpayment, medical negligence, or even fraud are dealt with in the manner that reduces your criminal and civil liability.