Michigan Healthcare Fraud Lawyer

Common Healthcare Fraud Allegations in Michigan

The scope of healthcare fraud activity in Michigan includes many different behaviors. Healthcare fraud accusations may involve billing for services that were never rendered, performing unnecessary medical procedures, or using incorrect billing codes to increase payments (“upcoding”). Some fraud cases include false representation of qualifications along with double billing practices and violations of Michigan’s drug prescription regulations.

Billing software misunderstandings or clerical mistakes can become grounds for investigations when suspicious patterns emerge from them. Insurance companies and law enforcement agencies use data analysis techniques to find potentially fraudulent activities, which allows investigators and insurance companies to flag unusual activity using statistics. The next step is usually for the investigating agency or insurance company to obtain records directly from the medical practice, interview patients, and compare actual patient treatment with what the provider billed to insurance.

An attorney review of the specifics after understanding the accusation helps determine whether it resulted from a criminal act or an administrative mistake.

Who Investigates Healthcare Fraud in Michigan?

Several agencies can handle healthcare fraud investigations in Michigan. The Michigan Attorney General’s Health Care Fraud Division at the state level often investigates both Medicaid fraud and provider misconduct. Private insurance cases can also start with an internal investigation by the insurance company itself, which triggers involvement from local law enforcement and/or Michigan’s Department of Insurance and Financial Services.

Healthcare fraud investigations are a major focus in Michigan. In 2023, the Michigan Department of Health and Human Services and the Office of Inspector General’s High Risk Medicaid Unit (HRMU) completed 1,899 high-risk Medicaid investigations, which led to the identification of $620,754 in fraud and $8.8 million saved through cost avoidance.

The Benefit Trafficking Unit (BTU) handled 720 investigations in 2023, which revealed $586,131 in fraudulent activities. The Special Investigative Unit (SIU) completed 118 investigations, which revealed $764,321 in provider, contractor, recipient, and employee fraud.

When healthcare fraud involves federal programs such as Medicare, it is usually forwarded to federal authorities, but state-level offenses may still result in major legal charges, significant penalties, and loss of medical licenses.

Before responding to any enforcement agency that reaches out to you, it is crucial to seek advice from a defense lawyer. Seeking legal advice early in the process safeguards your rights and helps avoid actions that might worsen your situation. Be aware that investigators from either the insurance company or a government investigating agency will often show up unannounced “just to ask a few questions.” You can politely inform the investigators that you would be happy to provide any information they need, but you would like to have a legal advisor there with you if this is an investigation before you answer any questions. Note that if the investigators have a search warrant, they can take documents from the practice, but you do not need to make a statement or answer any questions.