Health Care Fraud Cases

Being investigated by any governmental health insurance program carries with it both significant responsibilities and repercussions if the representation is handled incorrectly, wrong advice given, or false statements made to those investigators. Emergent counsel needs will become clear depending on the nature and extent of the investigation, employee conduct, and the amount of insurance proceeds secured through improper billing.

In the typical health care fraud indictment, the United States government charges both individuals in control of the company or the appropriate workers and the corporate with one or multiple counts of Health Care Fraud in violation of Title 18, United States Code, Sections 1347 and making False Statements Relating to Health Care Matters in violation of Title 18, United States Code, Section 1035(a)(2). Theft of government funds is also always present.

The factual allegations match the criminal violations of § 1347, by setting forth a factual scheme in which the perpetrators: knowingly and willfully execute, or attempts to execute, a scheme or artifice– (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services.

Charges of violationing § 1035 relate to false statements relating to health care matters. Here, whoever, in any matter involving a health care benefit program, knowingly and willfully– (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; or (2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry,

Lying to a § 1035 health care investigator regarding their investigation of the delivery of or payment for health care benefits, items, or services, garners imprisonment of not more than 5 years. Committing the fraud in any manner relative to falsifying submissions for payments of services not rendered in violation of § 1347 can warrant imprisonment of not more than 10 years. If someone is seriously injured due to the fraud (as defined in 18 USCS § 1365) the maximum is 20 years. If death to a patient results from the fraud, any term of years or for life is possible.

In one case, the court held that the record amply supports the jury verdict that the defendant, the owner of the company, directed his employees to falsify records so that they did not accurately reflect the deplorable conditions. The falsified records were then provided to the Pennsylvania Department of Health (“DOH”) for the specific purpose of deceiving it into believing that Atrium complied with applicable regulations, so that Atrium would maintain its certification under Medicare and Medicaid and, hence, the flow of government money. Bell was properly found guilty of health care fraud “based upon a scheme to falsify records” that she used “in an attempt to conceal from state and federal regulatory agencies the substandard care which was being provided to residents at Atrium. United States v. Bell, 2010 U.S. Dist. LEXIS 42947, 5-6 (W.D. Pa. May 3, 2010).

Please call to discuss your health care fraud investigation, questions, and compliance issues. Please visit my web site to review collateral licensure complications associated with any medical and nursing license issue.

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