Winning Federal Health Care Fraud Case Strategies

Korody Law is currently in the midst of litigating a highly contentious health care fraud case in federal court for the Middle District of Florida.  We recently filed a Motion to Dismiss Due to Prosecutorial Misconduct.

Fraud cases are exceedingly complex and involve voluminous discovery.  Winning a healthcare fraud case can be complex, and success depends on various factors, including the specifics of the allegations, the evidence available, and the legal strategy used. Here are some steps you can take to strengthen your case:

1. Consult an Experienced Attorney

• Hire a skilled health care fraud defense attorney: It’s crucial to have a lawyer who has experience with fraud cases and is invested in your case.  Bigger law firms may take your money and run through it billing excessive hours for unnecessary work before even the first pleading is filed. Look for a well-educated, well-respected trial attorney with fraud case experience in the area where the case will be tried.  They will help you navigate the legal process and develop a strong defense and, if necessary, hire additional counsel and experts to assist. 

2. Understand the Charges

• Identify the type of fraud: Health care fraud can involve a variety of charges, such as billing for services not rendered, upcoding, kickbacks, falsifying records, or submitting false claims. Understanding the precise allegations is essential to building a defense.  You have to carefully read the indictment, and if the indictment is vague your attorney needs to file a bill of particulars.
• Review discovery: Obtain and review discovery from the prosecutors.  This can be daunting a health care fraud case in a digital age.  There are often 100,000+ files that need to be reviewed.

3. Prepare Your Defense Strategy  Common defense strategies in health care fraud cases include:

• Lack of intent: Fraud requires an intent defraud. If the errors were unintentional, such as billing mistakes or clerical errors, you can argue that there was no intent to defraud.
• Mistaken identity or involvement: If you can prove you were not involved in the fraudulent activity or someone else was responsible for the errors, it could strengthen your defense.
• Compliance with regulations: Show that you followed proper procedures and adhered to regulations, minimizing the risk of fraudulent conduct. Proper documentation of compliance efforts can be vital.
• Insufficient evidence: If the prosecution’s evidence is weak or circumstantial, your lawyer may argue that the prosecution has not proven its case beyond a reasonable doubt.  This should be the defense of last resort in a health care fraud case.

4. Gather Evidence for Defense

• Conduct your own investigation: Gather all documentation related to the claims in question, such as medical records, billing statements, and correspondence with insurance companies or patients and provide it to you attorney.  The more organized the information is, the easier it will be for your legal team to digest.  Your legal team investigator should also interview and in some cases obtain sworn statements from witnesses.
• Expert testimony: Health care fraud cases often involve highly technical details, so having an expert in health care billing or medical practice to testify on your behalf can be critical.
• Demonstrate good faith efforts: Prove that you took steps to ensure compliance with regulations and corrected any potential errors once identified.  This may demonstrating the advice you received and operated under from those with knowledge in the field such as attorneys or accountants.
• Identify motives: Often, healthcare fraud cases rely on whistleblowers or former employees.  These individuals almost always have an ulterior motive, from disgruntled employee to qui tam litigant, that can expose the reasons why the witness may fabricate or embellish reporting.

5. Negotiate a Settlement (if appropriate)

• Plea bargain: If the evidence against you is overwhelming, your attorney may advise negotiating a settlement or plea bargain to reduce penalties or avoid harsher sentences.  In federal court, defendants normally receive and “acceptance of responsibility” reduction for pleading guilty.  However, any plea related to a health care fraud case normally includes significant restitution.
• Administrative resolution: In some cases, resolving issues through administrative actions like paying fines or agreeing to corrective measures may be an option