Federal Defense Against Healthcare Fraud

Defending Against Federal Healthcare Fraud Charges: A Guide for Lawyers

An Introduction to Federal Healthcare Fraud

Healthcare fraud refers to intentionally deceiving or misrepresenting information to obtain money or benefits from federal healthcare programs like Medicare and Medicaid. Common allegations include billing for services never performed, billing for unnecessary services, violating anti-kickback statutes, and more.

With healthcare occupying an ever-larger share of the U.S. economy, federal prosecutors aggressively pursue healthcare fraud cases. Charges often allege millions in improper billings over many years. Penalties can include massive fines, exclusion from federal healthcare programs, even imprisonment.

Understanding the Elements of Healthcare Fraud

While the specifics vary, most federal healthcare fraud charges include common elements like:

• Falsity – Evidence the defendant knowingly submitted false claims, records, statements or representations. Even if proper services were provided, erroneous information can support charges.
• Materiality – The falsehoods were “material” i.e. influenced the government’s payment decisions. Even minor billing errors technically violate the law.
• Knowledge and intent – Proof the defendant knew their actions were wrong and intended to defraud the government programs. As intent is hard to prove directly, prosecutors rely on circumstantial evidence.
• Damages – Quantifiable evidence of improper payments made due to the alleged fraud. The government uses statistical sampling and extrapolation to allege wider fraud beyond specific evidence.

Understanding these elements is key to developing defense strategies targeting weaknesses across them. For instance, while false billings may have occurred, can the prosecution clearly prove intent and knowledge?

Common Federal Healthcare Fraud Charges

Some of the most common federal healthcare fraud charges include:

1. Medicare/Medicaid Fraud

This encompasses billing government health programs for services not provided, billing for unnecessary services, billing for services not medically needed, and more. Penalties increase sharply above $1 million in alleged improper billings.

2. Anti-Kickback Violations

Federal law prohibits paying or receiving remuneration to induce referrals or orders for federally funded healthcare services. This includes lavish gifts, free rent, sham consulting fees, and more. More information on these violations can be found through the Office of the Inspector General.

3. Stark Law Violations

This civil statute forbids Medicare/Medicaid billing referrals from doctors with financial ties to medical providers. Unlike anti-kickback laws, prosecutors don’t need to prove intent under Stark.

4. Healthcare False Claims Act Violations

The False Claims Act allows whistleblowers and prosecutors to file civil charges for intentionally submitting false Medicare/Medicaid claims. Penalties can equal three times damages plus fines.

5. Obstruction of Justice

Destroying evidence, lying to investigators, or inducing others to obstruct justice often leads to serious criminal charges.

Key Considerations for Lawyers

Representing clients facing healthcare fraud investigations brings many case-specific complexities. But some key general considerations include:

• Retaining experienced healthcare fraud defense counsel immediately upon learning of an investigation. Early intervention increases chances of avoiding charges or securing a favorable settlement.
• Not rushing to turn over documents or make statements to investigators without guidance from counsel, as this can unintentionally aid prosecutors.
• Developing a deep understanding of the healthcare regulations and billing requirements related to the specific allegations and charges. The legal complexity cannot be overstated.
• Assembling a defense team with expertise in statistical sampling methodologies used by prosecutors to prove wider fraud beyond specific evidence. Challenging this extrapolation evidence could undermine damage claims.
• Never underestimating the government’s willingness to devote massive investigative resources towards securing healthcare fraud convictions. The reality is the deck is often stacked against defendants from the outset.

Conclusion

Defending against federal healthcare fraud charges presents perhaps some of the most legally complex challenges in the judicial system. The extremely high stakes make retaining specialized legal counsel immediately essential when facing a healthcare fraud investigation or indictment. Lawyers assisting clients must quickly get up to speed on the intricate healthcare regulatory framework central to most allegations. But by leveraging possible weaknesses in the prosecution’s burden of proof around intent, knowledge, falsity and materiality, skilled healthcare fraud defense lawyers can still mount an effective defense, even against the fierce resources brought to bear by federal prosecutors.