Healthcare Fraud

Healthcare Fraud

Prosecution and investigation of so-called healthcare fraud cases is now “front and center” to the Department of Justice. Its premise is that state and federal funds are used to support various programs, which are designed to provide needed medical treatment to the poor and elderly. Since the cost of Medicare and Medicaid programs are paid by the government, there is little incentive for program recipients or the healthcare providers to concern themselves with abuses in these programs.

The government views these types of fraud as complex and a successful investigation and prosecution will require the use of several investigative approaches. The department encourages successful prosecutors to prepare to attack the case from different angles.

The applicable statutes in these investigations is the mail fraud statute, and to kick back provisions of the Social Security Act, allege false, fictitious or fraudulent claims, false statements to federal agencies, racketeering, operating a continuing criminal legal enterprise and illegal drug distribution.

Investigative techniques are varied. They include: Undercover visits, use of computers, inspector general subpoena, “forthwith” subpoena and search warrants, audits by agency personnel as Grand Jury agents and use of low-level insiders. Frequently the aim is to secure billing records, which are to be obtained from the insurance carrier or the healthcare program. The investigation of claim forms is extremely important. Since these claim forms contain the services claimed in a code form, it is important that the client is familiar, as it is for his lawyer with Medicaid or Medicare code manuals which describe the various billing record to the various billing codes involved in a particular case.

The government will attempt to look at checks, check vouchers, computer printouts and miscellaneous identification matters, as well as correspondence, enrollment agreements, assignment agreements, code manuals and the healthcare provides records.

Stephen Jones has extensive experience in representing targets and subjects of these investigations across the country, including healthcare providers from California to pharmaceutical manufacturing companies in Philadelphia. He has represented numerous physicians as well as nurses and pharmacies in these investigations. He has had remarkable success, both at the trial and appellate levels.

In one particular case, where Stephen Jones did not represent the Defendant-doctor trial, he was able to secure a reversal of 40 of the 44 counts the doctor was found guilty of, and thus, maintained his license.

In another case, after two doctors were convicted in federal court, Jones was able to secure the reversal of the convictions. The United States Court of Appeals for the 10th Circuit found that the trial judge erred when he did not sustain Stephen Jones’ motion for directed judgment of acquittal at the end of the government’s case. The two physicians resumed the practice of medicine and in fact, one of them was crucial near the site of the bombing of the Murrah Building on April 19, 1995.

Yet, another pharmaceutical manufacturing company was indicted in the Federal Grand Jury in Oklahoma City and Stephen Jones secured an acquittal following a jury trial of his client.

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