Federal Defense Against Healthcare Fraud

An Introduction to Federal Healthcare Fraud

Healthcare fraud refers to intentionally deceiving or misrepresenting information to obtain money or benefits from federal healthcare programs like Medicare and Medicaid. Common allegations include billing for services never performed, billing for unnecessary services, violating anti-kickback statutes, and more.

With healthcare occupying an ever-larger share of the U.S. economy, federal prosecutors aggressively pursue healthcare fraud cases. Charges often allege millions in improper billings over many years. Penalties can include massive fines, exclusion from federal healthcare programs, even imprisonment.

Understanding the Elements of Healthcare Fraud

While the specifics vary, most federal healthcare fraud charges include common elements like:

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Legal Scenario: What Would You Do?

Scenario

You are a physician who owns a medical practice, and federal investigators have just served you with a subpoena alleging that your clinic submitted over $2 million in fraudulent Medicare claims for services that were never provided to patients. Your office manager confides that billing staff have been upcoding procedures for years, and you're unsure how much you personally knew about the practice.

Can I be held personally liable for healthcare fraud even if my staff handled all the billing without my direct involvement?

Attorney's Answer

Under 18 U.S.C. § 1347, the federal healthcare fraud statute, you can face up to 10 years in prison per count even if you did not personally submit the false claims — prosecutors only need to show you knowingly participated in or willfully turned a blind eye to the scheme. The government frequently uses the 'responsible corporate officer' doctrine and conspiracy charges under 18 U.S.C. § 1349 to hold practice owners accountable for systemic billing fraud occurring under their watch. An experienced defense attorney can challenge the government's evidence of your intent and knowledge, potentially negotiating with the Office of Inspector General and the U.S. Attorney's Office to reduce charges or pursue a civil resolution under the False Claims Act rather than criminal prosecution. It is critical that you do not speak to investigators or destroy any records, as obstruction charges under 18 U.S.C. § 1519 could dramatically worsen your exposure.

This is general information only. Contact us for advice specific to your situation.

• Falsity – Evidence the defendant knowingly submitted false claims, records, statements or representations. Even if proper services were provided, erroneous information can support charges.
• Materiality – The falsehoods were “material” i.e. influenced the government’s payment decisions. Even minor billing errors technically violate the law.
• Knowledge and intent – Proof the defendant knew their actions were wrong and intended to defraud the government programs. As intent is hard to prove directly, prosecutors rely on circumstantial evidence.
• Damages – Quantifiable evidence of improper payments made due to the alleged fraud. The government uses statistical sampling and extrapolation to allege wider fraud beyond specific evidence.

Understanding these elements is key to developing defense strategies targeting weaknesses across them. For instance, while false billings may have occurred, can the prosecution clearly prove intent and knowledge?

Common Federal Healthcare Fraud Charges