How Lawyers Defend Clients Against Healthcare Fraud Allegations

How Lawyers Defend Clients Against Healthcare Fraud Allegations

Being accused of healthcare fraud can be scary. The penalties are severe—we’re talking huge fines and even jail time. But with the right legal defense, many clients can fight the charges successfully. Here’s an inside look at how lawyers build winning cases for clients accused of healthcare fraud.

Understanding the Allegations

The first thing a good lawyer does is get crystal clear on what, exactly, the client is being accused of. Healthcare fraud covers a wide range of issues. Some of the most common allegations include:

• Billing for services that were never provided
• Billing for unnecessary services or procedures
• Billing for a more expensive service than was actually delivered
• Receiving kickbacks for patient referrals
• Prescribing medications for reasons other than medical need

There are also different parties who can face accusations—doctors, hospitals, drug companies, nursing homes, and more. The allegations could come from patients, competitors, or the Department of Justice.

Regardless, lawyers need to understand the full context behind the accusations. This includes getting copies of any official complaints and investigating the backstory.

Looking for Weaknesses in the Charges

Next, the legal team looks for weaknesses in the prosecution’s argument. Healthcare laws are extremely complex. There are often gray areas about what’s considered acceptable vs fraudulent. Lawyers analyze the charges to see if there’s room for a counter-argument.

For instance, ambiguous situations related to “medical necessity” are common. A lawyer may argue that a procedure was in fact necessary, even if it doesn’t appear so on the surface. Other weaknesses could include lack of proof, unreliable witnesses, missing documentation, or technical errors in the complaint.

If lawyers can demonstrate there are flaws in how the charges were brought, they may be able to get them dismissed before trial. Even if that doesn’t work, uncovering weaknesses lays the groundwork for creating reasonable doubt further on.

Looking for Mitigating Circumstances

Lawyers also look at the context and motivations behind the alleged misconduct. Were there extenuating circumstances that led the client to make poor choices? For example:

• A doctor bills for unnecessary procedures due to pressure from the hospital administration.
• A pharmacist fills suspicious prescriptions out of fear of losing patients.
• A medical equipment supplier pays kickbacks so they can stay financially viable.

While these mitigating factors don’t excuse fraudulent behavior, they can be used to create empathy and understanding from judges and juries. This is especially true if the client made poor decisions while trying to help patients.

Assembling Expert Witnesses

Credible expert witnesses are tremendously helpful for the defense. Lawyers locate experts like doctors, accountants, or former regulators. These experts can then explain why the client’s actions were reasonable given the circumstances.

For example, a physician may testify that controversial billing practices are common within the profession. Or an accountant could attest that the client’s financial records show no sign of ill intent. Expert opinions can powerfully refute assumptions of deliberate fraud.

Questioning Credibility of Witnesses

It’s not uncommon for disgruntled former employees or competitors to report healthcare providers to authorities. Their motivations may include revenge or eliminating competition.

In these cases, lawyers dig into the backgrounds of the accusing witnesses. The goal is uncovering anything that could tarnish their credibility, like:

• Previous legal issues or fraud accusations
• Questionable business practices of their own
• Biases, grudges, or other motives against the client

If lawyers can demonstrate witnesses have their own agendas or lack integrity, it weakens their testimony against the defendant.

Humanizing the Client

Lastly, good lawyers humanize the client by sharing positive details about their life story. They talk about details like:

• Family and relationships
• Professional background
• Charitable activities
• Awards and achievements
• Financial hardships

This gives prosecutors, judges, and juries a well-rounded view. The client becomes more than just “another fraudster”—they seem like a real person who made mistakes.

Humanizing creates empathy and helps convince the court to show leniency in sentencing if a conviction occurs.

The Bottom Line

With the right legal strategies, many clients can defend themselves successfully against healthcare fraud allegations. Lawyers aim to get charges dismissed pre-trial. But even if that fails, there are numerous techniques to create reasonable doubt or sway the court to be merciful.

By understanding the charges fully, finding weaknesses, uncovering mitigating factors, using experts, discrediting witnesses, and humanizing the client, lawyers can build compelling cases. No one wants to be accused of healthcare fraud—but an experienced legal team can help clients emerge with their reputation, career, and freedom intact.

References

Healthcare Fraud Laws and Regulations – https://www.law.cornell.edu/wex/health_care_fraud

Healthcare Fraud Investigations – https://www.justice.gov/criminal-fraud/health-care-fraud-unit

Mitigating Factors in Healthcare Fraud – https://www.wklawbusinesslitigationblog.com/health-care-fraud-investigations-look-for-mitigating-factors/

Using Experts in Healthcare Fraud Cases – https://www.hallrender.com/2019/02/27/the-importance-of-expert-witnesses-in-health-care-fraud-cases/

Credibility of Whistleblowers – https://www.americanbar.org/groups/litigation/committees/criminal/practice/2020/credibility-whistleblowers/