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When you’re facing a federal issue, you need an attorney whose going to be available 24/7 to help you get the results and outcome you need. The value of working with the Spodek Law Group is that we treat each and every client like a member of our family.

What Internal Medicine Doctors Need to Know About Healthcare Fraud

Internal Medicine Practices: Prime Targets for Government Investigations

If you have a successful internal medicine practice, you can easily become a target for government investigation. Internal medicine specialists are prime target for federal fraud investigations, Medicare billing extrapolations, and invasive ZPIC audits. Computer programs are designed to identify doctors to target by comparing doctors in similar specialties or geographic areas, which is a suspect method at best.

Because of these computer programs, internal medicine doctors in numerous states are being accused of healthcare fraud. Even the accusation alone puts them at risk of losing their reputation, license, and careers. Prosecution areas include:

  • Opioid Investigations
  • Fraudulent Home Healthcare Certifications (Form 485)
  • Medicare Billing Fraud
  • ZPIC Audits
  • Billing for Medically Unnecessary Services

If your practice is being audited by the Centers for Medicare and Medicaid (CMS) or a commercial insurance plan, or if you’re notified of a patient complaint regarding prescriptions of controlled prescriptions, or if you’re concerned about any other potential investigation against your practice, get help right away. If you wait to contact an experienced attorney, it becomes harder to defend and protect your interests.

The U.S. Justice Department has increased the scope and level of scrutiny regarding internal medicine specialists. Prosecutors investigate doctors for a variety of services, most often when those services are outside the doctor’s core practice. One example is that many internal medicine specialists serve hospice and home healthcare agencies, both of which are areas with rampant Medicare fraud issues. Doctors can get into legal problems by certifying, or recertifying, Medicare Form 485 if the government rules the patient wasn’t sufficiently examined or didn’t qualify for the certified services. Federal investigators and prosecutors have also increased their review of opioid prescriptions in internal medicine practices. The FBI and the DEA have arrested numerous internal medicine physicians in all states, charging that they violated the Controlled Substances Act by over-prescribing levels of opioids.

George FernandezGeorge Fernandez
14:16 30 Apr 24
Excellent 10 out of 10, Helped resolve my case. Jeremy explained everything and made everything easy to understand.
21:33 24 Apr 24
If you are looking for a lawyer that listens, is aggressive where needed, and holds his word above all else, Todd is the best pick. I had hired multiple attorneys prior to hiring the Spodek Group for a white collar case. The first thing that stood out to me was the cost, as anyone going through the process and dealing with the system, money was tight at that time - especially after hiring and firing multiple lawyers. The cost was not as high as others which was definitely a plus. Todd's intake process was also unlike other attorneys. He took the time to actually listen. He cared. He was trying to put himself in my shoes while I was explaining the situation to him and he really took the time to understand the whole situation. Other lawyers will give you 15 mins and send you a retainer agreement. Not Todd, I think he spent almost two hours with me as I was explaining everything.Not only was he great during the onboarding process, he was supportive and very informative through the entire plea process and eventually sentencing. After hiring him, I asked if I should hire a prison consultant, he told me to save my money as he would do everything they would. He was right and held up to his word. Later on I would hear from others that went with the prison consultants that they were a waste of money - I am glad I listened to Todd!When it came time for sentencing, two days prior to sentencing, the prosecutor tried increasing my proposed prison time by almost double - apparently a normal move. Todd and his team worked with me non-stop through the weekend prior to sentencing to ensure that I was not given additional prison time. Again, he took the time to listen and came up with a strategy to explain the case with great detail.Unfortunately, I did plead guilty as that was my best option. Todd and his whole team wrote up nearly 300 pages of a summary of what happened and why I should not be given prison time. If I breakdown the amount I spent with Todd versus the amount of work that I saw being done, I am shocked I was not charged four times as much. The other benefit was, a lot of criminal defense lawyers were just a single attorney with a paralegal or two. Todd had a team of people that I dealt with (5-7 people that I interacted with), but he was ALWAYS accessible. It would never take him more than an hour to reply unless he was in court.I was sentenced to prison and I was emotionally distraught. Todd and his team did whatever they could even after sentencing to make sure I was alright. He personally stayed in touch with my family to ensure I was doing alright and offered support to them. Most lawyers would consider the job complete at sentencing, not Todd.After prison, Todd still spent time with me to make sure I was on the right track and avoiding any potential risks in the future. He has also been giving advice on how to navigate probation etc and has not been looking at the clock for billing.Although I wish I had never been arrested in the first place, I am glad I had Todd and his team in my corner. Without them I likely would have had to spend a lot more time in prison than I did.Thank you, Todd, and the entire Spodek Law team, for helping turn what was a nightmare into a manageable situation!
Yelva Saint-PreuxYelva Saint-Preux
19:26 19 Apr 24
I am immensely grateful to the entire team at Spodek Law Group for their unwavering dedication and exceptional expertise throughout my case. From our initial consultation to the final resolution, their professionalism and tireless advocacy made all the difference. Their strategic approach and attention to detail instilled confidence in me every step of the way.Thanks to their hard work and commitment, we achieved a truly favorable outcome that exceeded my expectations. Not only did they navigate the complexities of my case with precision, but they also provided invaluable support and guidance during what was undoubtedly a challenging time. I cannot recommend Spodek Law Group highly enough, especially attorneys Todd Spodek and Claire Banks; they are beacons of excellence in the legal profession.YSP.
Katherine SunKatherine Sun
18:08 18 Apr 24
my lawyer is Alex Zhik. Efficient, patient and professional
Nun yaNun ya
17:48 18 Apr 24
Todd, Ralph and Alex are amazing. Helped my husband get from a double digit number with multiple charges to a single digit, by the time I blink he will be out. They very professional and help with all your needs. They dealt with my anxiety and worry very well and they understand that your family member needs to get home as soon as possible.
Keisha ParrisKeisha Parris
20:45 15 Mar 24
Believe every single review here about Alex Z!! From our initial consultation, it was evident that Alex possessed a profound understanding of criminal law and a fierce dedication to his clients rights. Throughout the entirety of my case, Alex exhibited unparalleled professionalism and unwavering commitment. What sets Alex apart is not only his legal expertise but also his genuine compassion for his clients. He took the time to thoroughly explain my case, alleviating any concerns I had along the way. His exact words were “I’m not worried about it”. His unwavering support and guidance were invaluable throughout the entire process. I am immensely grateful for Alex's exceptional legal representation and wholeheartedly recommend his services to anyone in need of a skilled criminal defense attorney. Alex Z is not just a lawyer; he is a beacon of hope for those navigating the complexities of the legal system. If you find yourself in need of a dedicated and competent legal advocate, look no further than Alex Z.
Taïko BeautyTaïko Beauty
16:26 15 Mar 24
I don’t know where to start, I can write a novel about this firm, but one thing I will say is that having my best interest was their main priority since the beginning of my case which was back in Winter 2019. Miss Claire Banks, one of the best Attorneys in the firm represented me very well and was very professional, respectful, and truthful. Not once did she leave me in the dark, in fact she presented all options and routes that could possibly be considered for my case and she reinsured me that no matter what I decided to do, her and the team will have my back and that’s exactly what happened. Not only will I be liberated from this case, also, I will enjoy my freedom and continue to be a mother to my first born son and will have no restrictions with accomplishing my goals in life. Now that’s what I call victory!! I thank the Lord, My mother, Claire, and the Spodek team for standing by me and fighting with me. Words can’t describe how grateful I am to have the opportunity to work with this team. I’m very satisfied, very pleased with their performance, their hard work, and their diligence.Thank you team!
K MarK Mar
01:37 25 Jan 24
I recently had Spodek Law Group represent me for a legal matter in NYC and I am thoroughly impressed with their services.Alex Zhik secured the best possible outcome for my case.It was a seamless journey from the initial consultation to the resolution of my legal matter. From the moment I spoke to Todd about my case, his enthusiasm to help was evident, setting a positive tone for the entire experience. The efficiency and professionalism displayed by the team is commendable.A particularly noteworthy aspect of their service is their user-friendly portal to upload your documents/evidence. This not only simplified the process, but showcases their commitment to streamline the client experience.Lastly, in an industry where legal fees can often be a concern, I found their pricing to be very reasonable, making needing legal assistance feel accessible and stress-free.I am grateful for their support and wouldn't hesitate to turn to them again in the future.

Our healthcare fraud and audit defense lawyers help you avoid criminal prosecution and license issues in extremely complex situations. Some examples include extremely high error rates, missing charts and notes, medically unnecessary procedures, billing for services not provided, and accusations of upcoding.

The sooner you contact an attorney when you’re being audited or investigated, the better your chances of concluding the audit without escalation. You’ll save considerable time, effort, and money by hiring experienced counsel right away.

CMS Audits and Investigations

CMS is the largest healthcare payer in the United States, and they are required by law to protect the Medicare Trust Fund. Every year, medical claims errors cost the agency tens of billions of dollars in inappropriate payments. To prevent these inappropriate payments for harming the Medicare Trust Fund, the CMS works with contractors and intermediaries to audit these claims. Examples of these relationships include:

  • Recovery Audit Contractor (RAC): RACs review claims post-payment with the goal of recovery inappropriate payments. RACs also notify CMS of any identified errors to help CMS prevent future inappropriate payments. RACs receive a percentage of the money they recover for CMS, which gives them the incentive to investigate aggressively. It also increases the likelihood that a provider will be involved with a RAC audit. These audits can trace back three years of past payments.
  • Supplemental Medical Review Contractor (SMRC): The SMRC is a national program intended to reduce improper payments by providing medical reviews for Medicare Part A, Medicare Part B, and Medicare DME claims. These audits are directed by CMS, and CMS determines the issues, scopes, and time frames for the audit.
  • Unified Program Integrity Contractors (UPIC): UPICs perform regional investigations to identify and prevent fraud, waste, and abuse for Home Health and Hospice (HH+H), Medicare Part A and Part B, Medicaid, DME, and Medicare-Medicaid data match program.
  • Investigations Medicare Drug Integrity Contractor (I-MEDIC): IMEDIC is designed to monitor any fraud, waste, and abuse initiatives for the Part C (Medicare Advantage) and Part D (Prescription Drug Plan) benefits.
  • Plan Program Integrity Medicare Drug Integrity Contractor (PPI MEDIC): PPI MEDIC provides prepayment data analysis, audits, and risk assessments for Part C and Part D plans. They also provide plan sponsor outreach and education.

As you can see, there any many programs and agencies designed to work against. Don’t stand alone in an audit: contact an attorney who specializes in healthcare fraud and audit defense today.

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