A court recently sentenced a Texas doctor to 10 years in prison and more than $26 million in restitution after a conviction for defrauding Medicare. The government built a successful case alleging the physician signed off on thousands of orders for genetic tests and orthotic braces that were not medically necessary. In some cases, the government established that the physician did not see, examine, or even speak to the patient before making the order.
Upon review of the evidence, a jury convicted the family medicine physician of conspiracy to commit health care fraud. The court recently sentenced him to 10 years imprisonment and over $26 million in restitution.
How does the government establish these claims?
The government must establish various elements to build its case. These include:
- False Statements or misrepresentations: The accused knowingly submitted false statements or misrepresented information to Medicare.
- Intent to deceive: The accused acted with the intent to deceive Medicare for personal or financial gain.
- Payment claims: The fraudulent claims resulted in unauthorized payments from Medicare to the perpetrator.
Understanding these elements helps to frame the legal thresholds that the prosecution must meet to secure a conviction.
What type of evidence does the prosecution use in Medicare fraud cases?
The government relies on a variety of evidence to substantiate their claims when prosecuting Medicare fraud. This evidence typically includes a review of medical records and billing statements to demonstrate discrepancies between services billed and services provided. Witness testimony also plays an important role in these cases, including statements from whistleblowers, coworkers, or other insiders who can provide firsthand accounts of the allegedly fraudulent activities.
These are just a few examples of the evidence the government will consider when establishing allegations of fraud.
Are these penalties typical for a Medicare fraud conviction?
The penalties above are in line with what the law allows in these types of cases. The consequences of a Medicare fraud conviction can be severe, impacting both individuals and institutions. Penalties often include:
- Fines and restitution: Substantial financial penalties and the requirement to pay back the defrauded amounts.
- Imprisonment: Depending on the severity and extent of the fraud, sentences can range from a few years to several decades.
- Exclusion from Medicare: Prohibition from participating in Medicare and other federal health programs, which can cripple healthcare providers.
Medical professionals who find themselves facing similar allegations are wise to take the matter seriously. Whether you received recent notification of an investigation or are facing charges, it is wise to act to protect your interests. A defense tailored to your specific case can help to mitigate the damage and better ensure your rights are protected throughout the process.
Attorney John Rivas is responsible for this communication.