How Lawyers Defend Healthcare Fraud Cases Involving Hospices

How Lawyers Defend Healthcare Fraud Cases Involving Hospices

Hospice fraud charges are serious business. They can wreck careers and land folks in prison. But with the right legal defense, you can beat the allegations. This article will go over how lawyers defend hospice fraud cases.

What is Hospice Fraud?

First, what exactly is hospice fraud? It’s when hospices bill Medicare for services that weren’t provided, aren’t medically needed, or misrepresent facts to get higher reimbursements. Some examples include:

• Billing for more expensive levels of care than actually given
• Keeping patients on hospice who aren’t terminally ill
• Falsifying diagnoses to qualify patients for hospice
• Paying kickbacks for hospice referrals

Most hospices follow the rules. But fraud does happen. And when caught, hospices face huge fines, civil lawsuits, and criminal charges.

Question the Medical Necessity

A big defense is challenging whether the care was really medically unnecessary. Lawyers dig into medical records looking for evidence it was justified. They’ll argue things like:

• “The clinical indicators supported the patient’s hospice enrollment.”
• “The care plan was within standards for a patient with these diagnoses.”
• “Experts disagree on prognosis – the doctor acted reasonably based on their judgment.”

If lawyers can show legitimate reasons for the care, it weakens claims of fraud.

Attack the Government’s Expert Witnesses

Prosecutors use expert witnesses to prove medical necessity and standards of care. But the defense tries to undermine those experts by:

• Questioning if they are qualified to judge hospice care
• Pointing out lack of recent hospice experience
• Arguing the standard of care is subjective

Discrediting the government’s experts makes it harder to prove improper medical care.

Blame Innocent Billing Errors

Lawyers may claim the false billing was just innocent mistakes, not intentional fraud. They’ll argue things like:

• “The billing agent made errors but the hospice wasn’t involved.”
• “The rules are complex – this was an honest coding mistake.”
• “There was a miscommunication about the level of care provided.”

While mistakes don’t justify false claims, it can cast doubt on intent to defraud.

Try Negotiating a Settlement

Many fraud cases settle out of court. This avoids an unpredictable trial. The hospice pays fines and penalties, but avoids criminal charges. Lawyers negotiate to get the lowest settlement possible.

Settlements often have confidentiality clauses too. This helps the hospice avoid bad publicity.

Argue Lack of Intent to Defraud

An important defense is arguing the hospice didn’t intentionally commit fraud. The lawyer looks for facts showing the hospice tried to follow rules and act ethically. This can defeat fraud charges that require willful intent.

Highlight Internal Compliance Efforts

Hospices can defend themselves by showing extensive internal compliance efforts like:

• Regular staff fraud training
• Internal audits to detect improper billing
• Protocols to ensure medical necessity

This demonstrates the hospice actively tried to avoid fraud rather than promote it.

Question Patient or Family Reliability

Often whistleblowers spark fraud investigations. So lawyers question the credibility of disgruntled patients or family members claiming unnecessary hospice care. They’ll argue things like:

• “The family didn’t understand the clinical indicators justifying hospice.”
• “The patient was confused or mistaken about their terminal prognosis.”
• “This is just retaliation by an angry former employee.”

Undermining accusers this way weakens their allegations.

Prepare Executives to Testify

Hospice executives often must testify. Lawyers prep them extensively to appear trustworthy, calm, and consistent. The goal is avoiding any damaging admissions when prosecutors cross-examine them.

Shift Blame to Staff

One tactic is blaming rogue employees – claiming any fraud was done without the hospice’s knowledge. Executives argue they had compliance policies to prevent fraud. This aims to insulate the hospice from liability.

Use Sentencing Guidelines for Leniency

If facing criminal conviction, lawyers use sentencing guidelines to argue for leniency. Factors like having a compliance program, cooperating with investigators, and accepting responsibility can significantly reduce sentences.

Summary of Defense Strategies

In summary, lawyers defending hospice fraud employ strategies like:

• Questioning the medical necessity
• Undermining the prosecution’s experts
• Claiming innocent billing errors
• Seeking a favorable settlement
• Arguing lack of intent to defraud
• Highlighting compliance efforts
• Attacking accuser credibility
• Carefully prepping executives to testify
• Shifting blame to individual employees
• Using sentencing guidelines for leniency

An experienced lawyer picks the best defenses based on the specific allegations and facts. Their goal is instilling reasonable doubt of fraud and avoiding liability. With the right legal strategy, even legitimate hospices can often successfully fight fraud charges.