Defending Doctors Against Philadelphia Medical Fraud Charges

Defending Doctors Against Philadelphia Medical Fraud Charges

Doctors in Philadelphia and across the country are facing increasing scrutiny and allegations of medical fraud. With complex billing procedures, heavy workloads, and reliance on staff, unintentional errors can occur and lead to criminal charges. Experienced legal counsel is essential to guide doctors through this difficult process and protect their interests.

Prosecutors must prove criminal intent to defraud in these cases. Honest mistakes, differences in interpretation, and unintentional errors may not warrant charges. Reliance on billing companies, staff errors, self-reporting of mistakes, and prompt corrections can be important defenses. Understanding the relevant laws and precedents is crucial:

“The government must prove beyond a reasonable doubt that the defendant knowingly and willfully executed, or attempted to execute, a scheme or artifice to defraud a health care benefit program, or to obtain money under the custody or control of a health care benefit program, by means of material false or fraudulent pretenses, representations, or promises.” United States v. Mitchell

“To convict a defendant of health care fraud under 18 U.S.C. § 1347, the government must prove beyond a reasonable doubt that the defendant knowingly and willfully executed or attempted to execute a scheme (1) to defraud a health care benefit program, or (2) to obtain money under the custody or control of a health care benefit program through false or fraudulent pretenses.” United States v. Iwuala

Doctors face immense pressure when confronted with fraud allegations. Even if charges are unfounded or eventually dropped, the reputation damage and potential license impacts can be severe. Many doctors are blindsided by the process and confusing legal issues. Experienced counsel is key to navigating this successfully.

Emphasize Unintentional Billing Errors

Medical billing and coding is incredibly complex, with thousands of service and diagnosis codes. Doctors rely heavily on staff and billing companies to handle this administrative work. With high patient loads, it’s impossible for doctors to be experts on billing intricacies.

Small errors like incorrect codes or documentation gaps can trigger fraud allegations. But these may simply reflect mistakes, not criminal intent. Skilled attorneys can explain how billing errors occur innocently despite a doctor’s best efforts.

“My client, like most doctors, relied on his billing staff and their medical coding knowledge for submitting claims. He had no intent to defraud insurers, and we will present evidence showing his team’s billing training and procedures.”

Note the High Bar for Proving Intent

Prosecutors face a high burden of proof for criminal healthcare fraud. They must demonstrate a doctor knowingly and willfully schemed to defraud insurers or government health programs. This requires showing intent – not just mistakes or negligence.

Billing for unnecessary services or procedures that weren’t performed can imply fraud. But other reasonable explanations may exist. Medical necessity can be open to interpretation. Services may have been provided but documentation lacking. Experienced attorneys can cast doubt on prosecutors’ version of events.

“The defense will show how treatment decisions were within the standard of care. Medical opinions may differ on necessity, but this doesn’t equate to provable criminal intent.”

Discuss Specific Defenses

Several defenses can be effective in fraud cases when applied strategically:

• Reliance on billing companies or staff – As discussed above, doctors aren’t billing experts. Delegating coding and claim submission to trained staff or companies means the doctor wasn’t directly involved in any fraudulent representations.
• Staff errors – Billers have heavy workloads too. They may make innocent mistakes that the doctor had no part in. This can defeat charges against the doctor.
• Self-reporting – Some doctors discover billing problems and immediately report them to authorities. This good faith action helps demonstrate lack of criminal intent.
• Corrective steps – If a doctor learns of inappropriate billing, actively fixing errors and implementing better processes shows a desire to get things right.

Skilled lawyers utilize defenses like these to undermine allegations of knowingly fraudulent conduct.

Reputational and License Impacts

Doctors’ reputations and livelihoods depend heavily on their licenses. Fraud charges alone can have devastating impacts:

• Media reports on charges, even if the doctor is never convicted, can harm reputations and patient trust.
• Regulatory bodies may open investigations and restrict or suspend medical licenses based solely on charges.
• Hospitals, health plans and other providers may terminate contracts even before any finding of wrongdoing.
• The provider’s DEA registration allowing prescription of controlled substances could be revoked.

Doctors should know they don’t have to face charges alone. Experienced attorneys can often head off or mitigate collateral impacts through aggressive advocacy.

The Costs of Legal Defense

Complex white collar criminal matters can cost hundreds of thousands – or even millions – in legal fees. Doctors don’t necessarily have this kind of money lying around.

Thankfully, options exist to fund a strong defense including:

• Malpractice insurance – Policies often include coverage for some fraud defense costs.
• Business insurance – For practices registered as corporations, business policies may offer protection.
• Asset protection – This can shield personal assets from being depleted in legal battles.
• Legal defense funds – Groups like the Doctors Company provide financing for fraud defense.

Doctors should review their coverage and seek expert advice on funding strategies. The right legal team doesn’t have to break the bank.

An Empathetic Approach Matters

The prospect of criminal charges is terrifying to doctors. Experienced counsel offers more than just legal expertise – they provide empathy and understanding.

From the initial shock of learning about allegations, through the anxiety of a regulatory or criminal probe, doctors need compassion. Defense lawyers who have been there before can provide reassurance and hope.

No doctor wants to face fraud accusations. But skilled attorneys can guide them through the process and out the other side. An empathetic approach, combined with fierce legal advocacy, can make all the difference.

Facing medical fraud charges in Philadelphia? Contact our team today. We’re here to help.