Health Care Fraud and Provider Billing Litigation Team

Fraudulent health care providers cost private benefit plans hundreds of billions of dollars annually.  Seyfarth’s Health Care Fraud and Provider Billing Litigation Team understands the stakes.  We are focused on helping our clients detect and remediate health care fraud before it becomes a “bet the company” problem.

Our cross-departmental, multi-disciplinary team of trial lawyers, ERISA counseling and litigation lawyers, and health care lawyers draws upon years of experience in complex litigation, health care law, ERISA and employee benefits, insurance coverage, white collar crime, fraud detection, and internal investigations to provide a wide range of advice and litigation services to our clients.  

Our team is uniquely qualified to represent health and welfare plans, corporate directors and officers, health care insurers and payors, risk managers, general counsels, health plan administrators, and trustees in all aspects of health care fraud allegations and litigation, provider billing litigation, and other reimbursement disputes.  We have particular capabilities advising Taft-Hartley plans on health care fraud and abuse issues.  We also represent providers falsely accused of fraud or falsely denied reimbursements.

With sophisticated knowledge of medical coding systems and claim form submissions, our attorneys help our clients prevent, detect, stop and remedy schemes by providers to overbill health plans and payors by submitting claim forms with false or incorrect information, such as: 

  • upcoding;
  • unbundling;
  • use of outdated codes;
  • misuse of modifiers;
  • billing for services not rendered;
  • double-billing; and
  • coding not supported by medical records. 
We advise our clients on all aspects of health care fraud, including:
  • improper fee splitting;
  • self-referrals;
  • the use of cappers and runners; and 
  • patient and provider kickbacks.

We advise ERISA plans, trustees and administrators on claims administration and on the application and enforcement of plan terms, including coverage exclusions for services that are experimental, violate established treatment protocols, or are not medically necessary.  We also handle disputes with third-party administrators, plan consultants, and other vendors. 

In litigation, we prosecute and defend cases involving claims of health care fraud, improper claims administration, non-allowable reimbursements, and provider billing.  We litigate claims under ERISA (including provider claims based on patient benefits assignments), the Stark Law, the Knox-Keene Act, RICO, the False Claims Act, the Criminal Health Care Fraud Statute and the Anti-Kickback Statute.  Our team also handles federal and state court litigation involving claims for breach of contract, intentional misrepresentation, negligent misrepresentation, concealment, conspiracy, estoppel, unfair competition, false advertising, conversion, and tortious and contractual interference.

We advise our clients in connection with health care fraud investigations by state and federal prosecutors, including the Department of Justice, the FBI, the Department of Health and Human Services Office of Inspector General, and the Department of Labor (Employee Benefits Securities Administration and Office of Inspector General).

Our team members frequently speak and publish on current trends in the investigation and litigation of health care fraud claims.

Health care fraud, reimbursement disputes, and provider billing litigation are on the rise. The landscape is changing and providers are using new and inventive methods to bill ERISA plans, health insurers, and other payors.  Implementation of the Affordable Care Act will increase incentives for providers to engage in such practices.  We are out in front of the trends in billing practices and related legal developments.