What is Healthcare Fraud and How is it Committed?

Healthcare fraud is a serious charge that is difficult to prove in court.

Almost any kind of fraud, which is basically a material misstatement made for the purposes of obtaining a pecuniary gain (lying for money), is a crime in Georgia. Frequently, these charges are federal cases since these schemes often cross straight lines and are extremely complex. A Ponzi scheme is a good example. For this reason, federal law enforcement authorities often take the lead in these cases.

Under the much-criticized separate sovereignties exception to the double jeopardy clause, state authorities can prosecute these crimes as well. The Fifth Amendment’s double jeopardy clause makes it illegal to try a defendant twice for the same crime. Separate sovereignties (state and federal prosecution for the same crime) are the biggest exception to this rule. Additionally, authorities may try a defendant twice for similar crimes but not for substantially similar crimes. Drug trafficking and drug possession are similar but not substantially similar.

As outlined below, because fraud investigations have so many moving parts, several defenses are available. A Georgia criminal defense lawyer can evaluate a healthcare or other fraud case and identify all possible defenses. With that knowledge in hand, it is much easier to successfully resolve these and other criminal charges.

Types of Healthcare Fraud

The healthcare market has exploded over the years and now exceeds $4 trillion a year in the United States alone. This huge industry also employs about 15% of the American workforce. Not all of these workers are honest. Some common types of healthcare fraud include:

• Coding: Generally, medical billers translate services rendered into codes, which are then transmitted to the government or a private healthcare insurance company for payment. There is not much of a difference between an X-ray and an MRI. They are both diagnostic tests. But there is a big difference in reimbursement level.
• MUS: A medically unnecessary service is a very subjective determination. Investigators and prosecutors often claim that redundant tests are MUS. However, when a Georgia criminal defense lawyer defends these doctors in court, the lawyer usually argues that the doctor was just being careful.
• SNP: Sometimes, service not provided fraud is straightforward. But that’s usually not the case. For example, if Dr. Y delegates a task to a nurse or a physician assistant, from one perspective, Dr. Y still performs the task, since the doctor is responsible for the task. Investigators and prosecutors often see things differently.

The healthcare market has exploded recently, and medical fraud cases have exploded as well. Several years ago, Medicare changed its reimbursement policies in a way that at least indirectly encouraged fraud. Medicare started reimbursing by the task, as opposed to reimbursing for each patient contact. Most private insurance companies followed suit.

Proving Fraud in Court

A healthcare fraud indictment is pretty much meaningless. A prominent federal judge once remarked that the procedure is so one-sided, and the burden of proof is so low that a prosecutor could convince a grand jury to indict a ham sandwich.

Once these cases get to a Fulton County criminal court, procedural and substantive defenses are usually available.

As mentioned, healthcare fraud investigations have lots of moving parts. Procedural defenses, like search warrant requirement violations, are common in these cases. Investigator A from agency Y assumes that investigator B from agency Z filed an affidavit or otherwise lawfully obtained a search warrant.

Substantively, prosecutors must establish guilt beyond any reasonable doubt. Generally, that means proving that the defendant had fraudulent intent and did not simply make a mistake.

Call a Gwinnett County Criminal Defense Lawyer Today

Healthcare fraud convictions have serious consequences. For a free consultation with an experienced criminal defense lawyer in Norcross, contact Zimmerman & Associates, Attorneys at Law. We routinely handle matters in Fulton County and nearby jurisdictions.