OUR EXPERIENCE

In recent years, state and federal authorities have significantly increased investigations and prosecutions of healthcare providers suspected of fraud, waste, or abuse. The arrival of a government representative—often without warning—almost always signals serious concerns. Whether it is an FBI agent, a Medicare or Medicaid surveyor, or an inspector from a state agency, these visits typically come unannounced and may occur during regular hours or off-hours when staffing is minimal. In such moments, investigators may attempt to gather more information than the law permits.

Every healthcare organization should have a clear, well-communicated protocol for responding to government inquiries. That plan must include immediate contact with legal counsel, both to guide staff in the moment and, when appropriate, to intervene directly.

Employees should always be courteous with investigators, but they must also understand that multiple legal and ethical considerations are at play—including patient privacy rights, employee rights, statutory protections for peer review materials, and privileges such as physician–patient and attorney–client confidentiality. While cooperation with law enforcement and regulatory officials is required, it must remain within the scope of their lawful authority.

The reasons for an investigation are not always apparent at the outset. They may stem from a whistleblower complaint, a government enforcement initiative, anomalies detected in an audit, follow-up on prior survey findings, or a specific complaint. Investigations can be civil, criminal, or both—making prompt legal advice critical to safeguarding the facility’s rights. Staff should know exactly who to contact if investigators arrive, have the facility attorney’s contact information readily accessible, and be clear on what may or may not be disclosed.

Healthcare facilities and their employees are legally required to cooperate with government investigations. State laws and federal regulations give agencies powerful enforcement tools. For example, Medicare rules authorize the Office of Inspector General (OIG) to exclude a provider from the program for denying access “upon reasonable request.” Investigators, however, cannot prevent personnel from speaking with their attorneys. Compliance with valid subpoenas and search warrants is mandatory; refusal can lead to severe penalties, including fines or imprisonment.

A thoughtful, well-documented response plan is therefore essential to any facility’s compliance program. This plan should address every type of potential contact with government or regulatory agencies—whether an audit, survey, inspection (announced or unannounced), subpoena, or search warrant—and detail exactly how the organization will respond.

At MDRXLaw, we routinely assist healthcare providers in high-stakes situations involving government inquiries. We respond rapidly, coordinate strategy, and provide experienced representation throughout the investigation process.