The U.S. Department of Justice (DOJ) continues to crack down on allegations of health care fraud. The agency has many different legal tools it uses to pursue those accused of a violation, including charges of conspiracy to commit health care fraud. This is a serious offense that involves two or more individuals planning to deceive health care programs for financial gain. To successfully prosecute a case of conspiracy to commit health care fraud, the DOJ must establish several key elements, including:
- Agreement: There must be evidence of an agreement between two or more parties to commit health care fraud. This agreement can be explicit or implicit.
- Intent: The individuals involved must have knowingly and willfully intended to commit fraud. This means they were aware of the fraudulent nature of their actions and chose to proceed regardless.
- Overt act: The prosecution must also show that the accused committed at least one overt act in furtherance of the conspiracy. This act does not need to be illegal in itself, but it must demonstrate the parties’ commitment to the fraudulent scheme.
Without clear evidence of an agreement, intent, and an overt act, the case may not hold up in court.
What are the penalties for a conviction for conspiracy to commit health care fraud?
The penalties are harsh and can include steep fines as well as imprisonment. In a recent example, the agency announced the indictment of two men for allegedly defrauding the government of almost $35 million in false and fraudulent claims for medically unnecessary devices. The agency claims the two paid illegal kickbacks to marketing companies to target Medicare beneficiaries and provide unneeded medical equipment. In addition to the conspiracy charges, they also face charges of health care fraud, wire fraud, conspiracy to defraud the United States and offering and paying kickbacks. If convicted, they face 65 years imprisonment.
What type of evidence does the DOJ use to build the case?
Once the DOJ identifies the elements of conspiracy, the next step is to gather evidence to support the case. This can include the use of investigators to review financial records, billing statements, and other documents to identify patterns of fraudulent activity as well as testimonies from whistleblowers, former employees, or other insiders can provide valuable insights into the conspiracy. In some cases, the agency may use surveillance and undercover operations in an attempt to gather direct evidence of fraudulent activities and the involvement of conspirators.
The DOJ’s approach to building a case for conspiracy to commit health care fraud is thorough and methodical. By focusing on the key elements of conspiracy and gathering substantial evidence, the DOJ aims to build a strong case against those accused of violation. Those who find themselves in the government’s crosshairs are wise to take the matter seriously. In addition to gaining a basic understanding of how the process works it is also important to begin taking steps to fight back against the charges. This can include gathering documentation to support medical decisions.
Attorney John Rivas is responsible for this communication.
