How Lawyers Defend Against Healthcare Claim Fabrications

Healthcare fraud is a serious issue that costs the industry billions of dollars each year. One common type of fraud involves patients or healthcare providers fabricating or exaggerating injury claims in order to receive higher insurance payouts. As a lawyer, it is important to have strategies to defend against fraudulent claims and protect your clients.

Investigating the Claims

The first step is to thoroughly investigate the claims being made. This starts with reviewing all medical records and documentation related to the alleged injury. Look for inconsistencies, missing records, or other red flags. Additionally, request to independently examine the claimant to look for signs they are embellishing or faking an injury. An experienced lawyer will know what details to look for[1].

Interview all relevant witnesses, such as treating physicians, nurses, coworkers, friends and family. See if their version of events matches up with the claimant’s story. Discrepancies in the details can reveal fabricated claims. Also look into the claimant’s background – do they have a history of fraudulent activities or making exaggerated claims in the past[2]?

Using Medical Experts

Retaining respected independent medical experts to review the claims is also essential. They can analyze if the medical evidence truly supports the alleged injuries, or if the records appear altered or do not match the stated symptoms. For example, soft tissue injuries like whiplash are commonly fabricated but an expert can identify inconsistencies. Have the expert thoroughly explain their analysis in a written report to use as evidence[3].

Challenging Suspicious Documentation

Scrutinize any documentation that appears suspicious, such as medical records that seem altered or bills for treatments that were never performed. Demand originals and run authentication tests. Question providers under oath about anomalies. Demonstrating a document is fraudulent can undermine the entire claim[4].

Deposing the Claimant

Deposing the claimant under oath is also an important step. This allows the lawyer to closely question them about inconsistencies in their story, especially details that do not match up with witnesses or records. Look for changes in their recollection or obvious signs of embellishment. Skilled lawyers can often get claimants making fabricated claims to contradict themselves or reveal lies during depositions[5].

Negotiating Settlements

Rather than going to trial, many fraudulent claims end up settling. This can still save substantially on payouts versus accepting the full exaggerated demand. A lawyer experienced in claim investigations can negotiate much lower settlements by presenting evidence of fabrication uncovered during discovery. Some claimants drop demands entirely once challenged with proof their claim is fraudulent.

Requesting an Independent Medical Exam

In personal injury cases, requesting the court order the claimant undergo an independent medical exam (IME) by the defense’s doctor can provide useful opinions. The IME may find no objective signs of injury or disability, undermining claims of severe harm. Some states limit requesting an IME to once, so timing it strategically is important.

Presenting Evidence in Court

If a reasonable settlement cannot be reached, then the lawyer must build the strongest case possible demonstrating the claim fabrication. Present all evidence gathered during discovery that contradicts the claimant’s version of events or reveals lies stated under oath. Use medical experts to persuasively explain how the records and symptoms do not match the stated injuries. Point out where financial motive influenced exaggeration or faking of claims.

Arguing Against Damages

The defense lawyer should argue against the requested damages even if some legitimate injury occurred. For example, challenge the extent of disability claimed, especially if the claimant was observed performing activities that exceed stated limitations. Argue surveillance evidence demonstrating exaggerated impairment. Dispute the need for ongoing treatment or medications well beyond normal recovery periods.

Utilizing Legal Defenses

Certain legal defenses may also defeat fraudulent claims. For example, the statute of limitations may have expired before the claim was filed. In some cases, disproving just one key element of the claim makes the entire case fail. Arguing comparative negligence when the claimant’s own actions contributed to the incident can reduce damages.