Criminal Defense Lawyers

Defending Federal Healthcare Fraud Charges: An Overview

Defending Federal Healthcare Fraud Charges: An Overview

Dealing with federal healthcare fraud charges can be an incredibly stressful and complex situation. As a healthcare provider, you have a duty to provide quality care for your patients – but you also need to ensure compliance with complicated regulations. An accusation of fraud means your medical license, livelihood, and even freedom may be at stake.

This article aims to provide an overview of common federal healthcare fraud charges, potential penalties, and practical tips for building an effective legal defense. We’ll also discuss when it makes sense to fight the charges versus attempting to negotiate a settlement.

Understanding Healthcare Fraud Allegations

Healthcare fraud refers to an intentional deception perpetrated to receive money or benefits from a healthcare program like Medicare or Medicaid. Common allegations include:

• Billing for services never performed: This covers billing for fake appointments, upcoding services (billing for more complex procedures than were actually done), and billing for care provided by unqualified staff.
• Misrepresenting diagnoses: This includes diagnosing conditions that don’t really exist in order to justify tests, procedures, prescriptions, etc.
• Violating the Anti-Kickback Statute: This federal law prohibits paying or receiving compensation to induce referrals for healthcare services covered by federal programs.
• Misusing patient information: This includes using patient data without consent or selling patient medical records.

Federal prosecutors take healthcare fraud very seriously – especially anything involving public healthcare programs, as that constitutes fraud against taxpayers. Charges often come after an audit or investigation by agencies like the HHS Office of Inspector General.

Understanding the Consequences

The penalties for a federal healthcare fraud conviction can be severe. They may include:

• Prison time: Healthcare fraud involving public insurance programs like Medicare is a felony charge, with sentences up to 10 years per offense. Submitting a high volume of fraudulent claims can result in decades behind bars.
• Fines: A single fraudulent claim over $100,000 can trigger fines up to $500,000 for an individual or $1 million for a corporation. The total fines often reach millions of dollars.
• Asset forfeiture: The government can seize personal and business assets obtained through fraudulent activity – your home, bank accounts, vehicles, etc.
• Exclusion from federal healthcare programs: An exclusion means you can no longer bill, refer patients, or prescribe medications for any federally funded program. This effectively ends involvement in public healthcare. Exclusions often last a minimum of 5 years.
• Loss of medical license: Most states will revoke a physician’s license after a felony fraud conviction, meaning the end of your medical career.

Suffice to say, the stakes are extremely high, and the consequences can be devastating. Constructing an effective legal defense is critical.

Building a Strong Defense Strategy

Here are some key elements to discuss with your legal team as you build a defense strategy:

1. Evaluate the Strength of the Government’s Case

Your attorney will thoroughly review the prosecution’s evidence and witnesses to identify holes in their argument. This involves checking medical records, financial statements, and other documentation to ensure the facts fully support each charge.

If flaws exist in the government’s reasoning or documentation, those become leverage to get charges dismissed or reduced. Common mistakes that weaken the prosecution’s case include:

• Relying on the testimony of witnesses with credibility issues
• Failing to prove you acted “knowingly and willfully” (with intent)
• Having weak or contradictory documentation backing up the charges

Pinpointing those weaknesses lays the foundation to undermine the prosecution’s entire argument.

2. Present Evidence of Your Innocence

In building a defense, you’ll gather exculpatory evidence proving lawful and appropriate conduct. For example:

• Documentation of medical necessity: Charts, scans, lab results, etc. proving you actually diagnosed and treated the billed conditions.
• Evidence of honest mistakes: Documents showing an error led to incorrect billing, such as a coding mistake.
• Proof you acted in “good faith”: Records demonstrating you attempted to comply with complex billing rules.

Essentially you’re gathering evidence to conclusively demonstrate you did not intentionally mislead or deceive the healthcare programs.

3. Consider Using Affirmative Defenses

Certain circumstances excuse otherwise unlawful actions. Common affirmative defenses in fraud cases include:

• Lack of criminal intent: This means you made an honest mistake rather than willfully or knowingly committing fraud.
• Entrapment: This argues that government informants improperly induced you into committing fraud.
• Duress: This means you were somehow coerced into acting unlawfully by threats of harm.
• Statute of limitations: This argues too much time has passed between the alleged crimes and the charges being filed.

Discuss any scenarios with your legal team that could potentially constitute an affirmative defense.

4. Attempt a Settlement

Settlement negotiations happen behind the scenes and can potentially happen at any time. In many cases they allow a defendant to avoid harsh penalties with an admission of guilt. Typical settlements require:

• Repaying any unlawfully obtained money
• Paying fines/penalties
• Cooperating with investigators
• Establishing a compliance program
• Agreeing to exclusion from federal healthcare programs

If you believe you have a strong case but want to avoid risking trial, a settlement bringing closure may be preferable. An experienced legal team can advise you on the pros and cons here.

Finding the Right Lawyer for Your Defense

Assembling a seasoned legal team familiar with both healthcare operations and federal fraud statutes is absolutely vital. Key credentials to look for include:

• Previous experience with healthcare fraud cases – especially those involving federal prosecutors.
• In-depth knowledge of billing regulations across Medicare, Medicaid, Tricare, etc.
• The skills and staffing to deeply investigate your situation.
• A track record of successfully defending other physicians.
• Strong relationships with prosecutors and regulators.

Don’t take chances with underqualified counsel in over their heads. Vet any potential hires rigorously.

Healthcare fraud charges have life-changing implications. But an experienced legal team can analyze the evidence, formulate a defense strategy, and negotiate for the best possible outcome under the circumstances. With their guidance, you may be able to resolve the case while avoiding harsh penalties.