Health Care Fraud

A major emphasis of modern day federal grand jury investigations is health care fraud, an explosive problem involving billions of dollars.

Health care fraud is rampant, unfortunately, because of the ease with which health care providers can apply for Medicare and Medicaid benefits. There are simply too many providers to audit. Unfortunately, many providers submit documentation, which on its face appears to be a reasonable request for payment under the Medicare / Medicaid programs, but in reality, is fraudulent and falsified.

The U.S. Department of Justice has a variety of tools to combat health care fraud. Because such schemes are sophisticated, typically the conspiracy statute and the major fraud statutes referenced above are commonly utilized. Another tool being used by the U.S. Government are “Qui Tam” lawsuits filed by whistleblowers. Oftentimes an insider becomes aware that a health care provider is upcoding or otherwise filing claims for services not rendered. A whistleblower civil lawsuit can serve as the basis for a subsequent criminal prosecution. More and more federal criminal investigations are predicated upon whistleblower lawsuits which bring to the attention of the government insider knowledge concerning fraudulent activities.

Our firm has represented many health care providers including doctors, physician groups, and major health care provider corporations. Finch McCranie LLP represented the consultant to Columbia/HCA hospitals when that company was charged with over $700 million of health care fraud. That criminal case is today still one of the largest ever in U.S. history. The firm’s client (the coding consultant company to Columbia/HCA) was exonerated despite 3 FBI search warrants, and multiple grand jury subpoenas. The consultant’s advice was good but had been either ignored or misapplied as was demonstrated by the firm’s investigation on behalf of the client. After extensive negotiations, the Department of Justice declined the case against the client.

While schemes to defraud take a variety of forms and come in a variety of different “shapes and sizes” typically all such cases involve allegations of either outright theft from the Medicare/Medicaid program or overcharging the government under the terms of each. As many cases evolve either through the grand jury process or through Qui Tam lawsuits, our lawyers are uniquely positioned to provide representation to those being investigated or prosecuted in such cases as our attorneys have backgrounds both representing whistleblowers, defending health care providers and, as former federal prosecutors, investigating health care billing issues. If you or your company is being investigated for health care fraud, please contact us today for a  consultation.