Healthcare Investigations

Results achieved in prior matters are not meant to be a guarantee of success as the facts and legal circumstances vary from matter to matter.

At Wilentz, Goldman & Spitzer, P.A. we provide a highly qualified criminal defense team with a long history of success in managing and resolving healthcare-focused audits and investigations. We work in concert with our Health Law attorneys on behalf of our physician, dentist and other licensed healthcare professional clients including ophthalmologists, nurses, physician assistants, physical therapists, optometrists, psychiatrists, psychologists, and social workers that have become targets for audits, investigations and related regulatory inquiries brought by insurers and state and federal regulators. As an integrated defense team, we seek to obtain positive outcomes in audits and investigations. We are prepared to develop remedial and compliance plans that appropriately address potential liabilities to prevent audits and investigations altogether.

Audits and investigations in the healthcare industry often arise from inquiries and allegations associated with:

  • “Up-coding” and/or “over-coding” payor claims
  • Fraudulent billing
  • “Kickbacks”
  • In-network audits
  • Licensing issues
  • Medicare and Medicaid investigations

Because criminal investigations are fact sensitive, outside auditors and consultants are often retained to calculate figures and related discovery during audits and investigations. Insurance company audits are not uncommonly based on inaccurate data and may be flawed, either by a lack of depth or inaccurate metrics needed to prove claims for refunds of billings.

Our Criminal Law practice is among the most-established state and federal practices in New Jersey. Our team is led by a certified criminal trial attorney and includes former prosecutors who have distinguished themselves in difficult and highly publicized cases.

It is important to retain counsel early on in a healthcare investigation. Our Health Law and Criminal Defense team has a synergy that our clients find uniquely benefits the outcome of their matter, and provides the comfort and ease of continuing to work with their trusted primary legal advisor.

Medicare and Medicaid Investigations

At Wilentz, we provide a highly qualified criminal defense team with a long history of success in resolving investigations arising from billing issues through Medicare and Medicaid. Both healthcare programs are federally funded, heavily regulated, and administered by the federal government or through states that have allocated Medicare and Medicaid funds. Oftentimes, these investigations are initiated by the Office of Inspector General (OIG) of the United States Department of Health and Human Services, and may be triggered by errors in coding or in the number of hours billed.

We work in concert with our Health Law attorneys on behalf of our physician, dentist, and other licensed healthcare professional clients as an integrated team to respond to subpoenas issued by the OIG, to identify problem areas early on, and to respond to government investigators.


Darren M. Gelber Photo

Darren M. Gelber
Chair, Criminal Law Team

Michael F. Schaff Photo

Michael F. Schaff
Co-Chair, Corporate, Health and Cannabis Law Teams