This is almost invariably one of the first questions healthcare providers ask during our free initial case assessments. Unfortunately, it is also one of the most difficult questions to answer with any degree of specificity at this initial stage. However, the general answer is this: In recent years, federal agencies, including the Department of Justice (DOJ), Drug Enforcement Administration (DEA), and Office of Inspector General (OIG) have ramped up their efforts to protect federal healthcare benefit programs (i.e., Medicare, Medicaid, and Tricare) against fraud and abuse. While these efforts initially focused on targeting fraudulent enterprises, today these agencies launch investigations into legitimate healthcare providers' billing practices on a daily basis.
In many cases, these investigations are simply random. However, federal authorities may also choose to investigate a provider if the provider's billing data is anomalous when compared to other similarly-situated providers. The investigation may also be initiated if the authorities receive a whistleblower complaint from an employee, patient, or competitor.