Understanding Federal Healthcare Fraud and Defenses Against It

Healthcare fraud is a federal offense that consists of intentional deception or misrepresentation of information in order to obtain benefits from Medicare, Medicaid and other government-funded insurance plans. This type of fraud can include many types of dishonest activities, such as knowingly submitting false claims or overbilling for healthcare services. However, it must involve intentional acts in order constitute a federal crime.

Healthcare fraud may be prosecuted under the False Claims Act (FCA), the Anti-Kickback Statute (AKS) and the Health Care Fraud Statute, 18 U.S.C. § 1347. Prosecutors can target any of the following individuals and entities in the healthcare industry:

• Doctors, nurses and other medical professionals, for inflating bills, billing for services not rendered or performing unnecessary procedures
• Office managers or billing personnel, for knowingly submitting fraudulent claims to insurers or to federal programs
• Patients, for using false identities or providing inaccurate information to obtain benefits they are not entitled to
• Hospitals, clinics, laboratories or pharmaceutical companies, for engaging in systemic fraudulent practices to maximize profits
• Vendors, contractors or consultants, for participating in schemes to defraud healthcare programs

To convict someone of federal healthcare fraud, prosecutors must prove the following:

• Intent — The accused must have knowingly and willfully engaged in a scheme to defraud a healthcare program. This means having knowledge the claim was false at the time it was submitted.
• Deceptive conduct — The fraud typically involves false statements, misrepresentations, or omissions intended to deceive.
• Materiality — The deceptive conduct must be material, meaning it has the potential to influence the payment decision of a federal healthcare program.
• Connection to federal funds — The fraud must involve programs like Medicare, Medicaid, or other federally funded healthcare services.

If you’re charged with federal healthcare fraud, several defenses may be raised, among them:

• Demonstrating that the alleged actions were unintentional mistakes, such as clerical errors, can negate the requirement of willful intent
• Challenging the sufficiency or reliability of the evidence presented by prosecutors can cast doubt on the validity of the charges
• Showing adherence to applicable billing and coding guidelines may establish that no fraudulent activity occurred
• Arguing that the alleged misrepresentation had no material effect on payment decisions may weaken the prosecution’s case

Given the severe penalties resulting from conviction of healthcare fraud, including fines, imprisonment, and exclusion from federal programs, individuals and entities accused of healthcare fraud should seek experienced federal criminal defense counsel.

The dedicated criminal defense attorney at the Law Offices of David Jay Glassman in Philadelphia provides an aggressive defense to federal healthcare fraud charges. To arrange for a confidential legal consultation, call us at 215-563-7100 or contact us online.