Articles Posted in Health Care Fraud

I was just reading a press release from the U.S. Attorney for the Northern District of Georgia, based here in Atlanta a few blocks from my office.  The prosecutors touted their recent indictment of a physician’s assistant for supposed health care fraud and other crimes.  Reading this made me want to put down a few thoughts about such cases, which we have handled multiple times over the recent years.

Anyone reading our website knows that there are “federal fraud” cases, and then there are sub-species of federal fraud.  Health Care Fraud is an especially dangerous and pernicious charge to defend against.  For starters, the wickedly complex Federal Sentencing Guidelines  make the potential sentences for Health Care Fraud even longer than what is suggested for regular run-of-the -mill fraud.  Certain “specific offense characteristics” bump up the scoring mechanism when prosecutors include an allegation that an accused person’s supposedly fraudulent conduct violated one of the Health Care Fraud laws that Congress has enacted over the years.

The accused person and his or her lawyer also need to be keenly aware that there are sub-sets of Health Care Fraud.  For example, there is an illegal “kickback”, which the Government defines as: “the knowing and willful payment of ‘remuneration’ to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (e.g., drugs, supplies, or health care services for Medicare or Medicaid patients)”.  Anti-kickback cases are weirdly complicated with many people wondering why the Feds are interested in the normal back and forth payments that arise in many sectors of our economy.

Many times I am hired when a person or company is under investigation for supposedly committing a crime, both in and near Atlanta and throughout the State of Georgia and in other parts of the United States (and sometimes even in foreign nations).  Some of these investigations turn into criminal cases.  Other times, no charges are brought.  However, today I want to talk about a third type of result; when the criminal case turns into a civil settlement.

Many businesses operate in a highly regulated environment.  For example, companies that provide services that are paid by Medicaid/Medicare or an insurance company almost always have to comply with lots of rules and regulations that in the end come out of the United States Department of Health and Human Services (“HHS”).

For a few years I’ve been working with some extremely honorable folks who operate several businesses that provided mental health and other services to poor people.  Sometimes, they even give free housing, transportation and food to the poor.  The payments for mental health services were provided from federal money that went to the State of Georgia.  All this federal money comes with lots of federal regulations that must be complied with. Continue reading

We are seeing more and more federal criminal prosecutions for alleged medicaid fraud, here in Atlanta, throughout Georgia, and in other cases that take us to other parts of the country.  Whenever federal prosecutors bring up these kinds of charges, they almost always issue a press release.  The local media lap up these press releases like kittens at a bowl of milk.  Because of ethical and constitutional issues, these press releases always include a line to the effect that the indictment, issued along with bells and whistles and a press release, only “contains charges” and the public should remember that the charged persons are “presumed innocent.”  Here is a recent example of one such press release.

A lawyer handling the defense of a person accused of defrauding the medicaid system has a lot of work on his or her hands.  First, the law is complicated.  The facts are usually very complex.  The information is almost always voluminous.  The practice of medicine, providing mental health services, or selling products or drugs to be used in the medical field are all businesses that generate gigantic amounts of information and data.  We are regularly amazed at the volume of material we need to assess when representing our clients in one of these highly sophisticated types of federal criminal cases.

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One of the white collar federal criminal cases me and my partner Carl Lietz have handled here in Atlanta involved a very successful local radiologist. The doctor came to see us after being represented by some other very accomplished attorneys. We took on his case, fought very hard, yet lost the trial in the summer of 2011. The doctor went to prison, but we kept fighting by asking the Court of Appeals to reverse his convictions. This past Friday morning, our efforts paid off, in that the Court of Appeals reversed each and every one of the 35 charges against the doctor. Here is a short version of the story, which should be a lesson for all lawyers and clients on how important it is to make long-range plans while in the middle of a hard-fought trial process.

The government’s basic allegation was that our client submitted tens of thousands of radiology “reports”, without himself or any other doctor actually looking at the x-ray or other image that was the subject of the report. Some staff members said it looked like he was doing that. Furthermore, the computer system logs only showed him accessing the associated images about 5000 times out or the 72,000 reports issued over his signature. The government’s case was made even better when they demonstrated that some reports were issued while he was on vacation or even on international airline flights.
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A decision from an Atlanta case that was issued last Friday once again demonstrates that sentencing hearings in federal criminal cases are amazingly complex, and can lead to surprises. In the case from last week, US v. Kuhlman, the Sentencing Guidelines called for a range of 57-71 months in custody. Prosecutors asked for 36 months. The Defendant paid almost $3 million in full restitution. The Judge continue the case for 6 more months, during which time the Defendant performed almost 400 hours of community service. At the next sentencing hearing, the Judge decided it made no sense to put the Defendant in prison, so he imposed a “time served” sentence. The prosecutors appealed, and the Court of Appeals agreed with them, reversing the probationary sentence and remanding for another sentencing hearing.

The Defendant was a local Atlanta area chiropractor who owned and operated a series of clinics. Beginning in January 2005, he began a five-year scheme, falsely billing health insurance companies for services he knew were not rendered to his patients. The Defendant was charged in a criminal information with one count of health care fraud in violation of 18 U.S.C. §§ 1347 and 2. He pleaded guilty pursuant to a plea agreement. At the plea hearing, the chiropractor admitted that he did not steal out of need-he was not in financial trouble and he did not have creditors breathing down his neck asking for money. Instead, he conceded that he simply pushed the envelope of billing practices.
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