Fighting Back Against Healthcare Conspiracy Allegations

Lawyers representing healthcare providers often face allegations from government agencies or whistleblowers of participating in widespread conspiracies to defraud healthcare programs. These allegations can seem daunting, but skilled legal counsel can mount strong defenses to protect their clients. This article provides an overview of common allegations, key precedents, and effective strategies lawyers employ.

Scrutinizing the Charges

The first step is scrutinizing the actual charges, which fall into three main categories:

• Healthcare fraud – billing government or private insurance for unnecessary or fake services
• Kickbacks – paying doctors, patients or others for referrals tied to medical services
• Misbranding drugs – selling without FDA approval or evidence of safety

In particular, prosecutors must prove specific elements like falsity of claims, knowledge of wrongdoing, and amount of harm. Lawyers can argue the services were legitimate, errors were unintentional, or damages were exaggerated.

Assessing the Quality of Evidence

Next, review the caliber of evidence behind the allegations, which may originate from whistleblowers, audits, confidential informants, or undercover operations. But this evidence can lack context, draw speculative conclusions, or derive from questionable sources.

For example, disgruntled former employees may present misleading information out of bitterness over their termination. Or investigators could take isolated documentation deficiencies as indicative of systemic abuses without considering mitigating factors. In other cases, there may simply be a lack of witnesses or paper trails to corroborate accusations of secret schemes.

Employing Legal Defenses

A standard defense is attacking the legal interpretation of rules applied to healthcare billing and referrals[5]. Complex regulations like the Federal Anti-Kickback Statute or Stark Law contain nuances and exceptions that aggressive prosecutors sometimes disregard. For instance, financial relationships with referral sources can be permissible if properly structured to fit safe harbor provisions.

Beyond technical defenses, lawyers employ arguments regarding the right to due process under the law. For example, sentencing guidelines that seem excessive compared to the actual harm caused or the defendant’s level of intent. Judges have considerable discretion to adjust penalties downward in the name of fairness.