Melissa Jampol Quoted in "Don't Let a Health-Care Claim Dispute Become a Billing Fraud Case"

Health-care providers facing billing disputes with commercial health insurance companies need to take measures to ensure those disputes don’t morph into civil and criminal enforcement actions.

Health lawyers who represent providers in health-care billing disputes told Bloomberg Law they have been seeing more civil actions based on health insurer fraud unit investigations. They say the involvement of these units also can lead to cases being referred to law enforcement for criminal fraud prosecutions…

“There is no doubt that payers are bringing cases to state and local law enforcement, because they are finding what they believe to be fraud,” Melissa L. Jampol, a former federal prosecutor, who now defends health-care providers with Epstein Becker & Green in New York, told Bloomberg Law.

According to Jampol, a commercial insurer’s SIU can often have staff members with law enforcement experience. “If you look at who is in those SIUs, they are often staffed by people who formerly worked for the HHS Office of the Inspector General, or the Federal Bureau of Investigation, or in a state’s Medicaid fraud unit,” she said.

That information could lead to criminal charges under 18 U.S.C. § 1347—a federal health-care fraud statute that was added in 1996 as part of the Health Insurance Portability and Accountability Act (HIPAA)—or under the Anti-Kickback Statute or related federal criminal statutes involving conspiracy, wire fraud, and mail fraud. “When you see press releases from the Department of Justice announcing pleas in criminal cases, you would never know from their face that there was significant payer help on the front end,” Jampol said.

However, she added, most law enforcement officers aren’t going to just rubber-stamp fraud claims brought to them by commercial insurers. “I know the prosecutors I worked with in the Health Care Fraud Unit at the U.S. Attorney’s Office in the District of New Jersey wouldn’t just accept a ready-packaged case,” she said. “There is a commitment to uncovering actions that could amount to fraud. Often, in the regular course of those investigations one of the first things a prosecutor will do is to look at who has complained about potential fraud, including complaints to payers, and use those complaints, as well as any related SIU investigation, as a starting point,” she said …

Providers who are facing aggressive audits and involvement of SIUs are best advised to get ahead of the investigation by engaging directly with the investigators early on …