Congress
criminalized fraudulent activities committed against
health care benefit programs, with the addition of
Section 1347 on August 21,1996. The goal of health
care fraud is to attain a desired result by trickery,
concealment, dishonesty and/or deception, a lot like
other white collar crimes. However, with health care
fraud, the final intent is to get over on an actual
health care program. Before 1996, mail and wire fraud
were the more predominant statutes utilized by the
United States Attorney's Office to prosecute frauds
committed against health care benefit programs.
In general,
most federal jurisdictions, to convict a person
of health care fraud, an Assistant United States
Attorney (AUSA) must present evidence that when
submitted to a jury or judge would prove beyond
a reasonable doubt:
1. Such said defendant knowingly and willfully carried
out, or attempted to carry out, a scheme or hoax;
2. to cheat any health care benefit program; or
3. to acquire, by means of false and/or fraudulent
pretenses, representations, or promises, any of
the monies or property owned by, or under the custody
or control of, any health care benefit program;
and
4. in link with the transfer of or payment for health
care benefits, items, or services.
How have
the courts defined health care violations?
A. A defendant had ordered unnecessary medical tests
from an entity owned by his sister-in-law and her
husband. He received office space, staff, and marketing
services, in return. Agreeing on a conviction for
health care fraud, the court determined, that in
order to be convicted for health care fraud, "proof
is not required that the defendant received direct
financial acquisition from his actions." Indeed,
the law defines intent to defraud as "acting
willfully and with specific intent to deceive or
cheat, usually for the purpose of getting financial
gain for one's self or causing financial loss to
another, not as requiring both financial gain to
oneself and financial loss to the victim."
United States v. Davuluri, 239 F.3d 902, 906 (7th
Cir. 2001); quoting United States v. Moede, 48 F.3d
238, 241 (7th Cir. 1995)
Possible
Penalties:
A
person may be found guilty of a felony, sent to
prison for up to 10 years, and fined up to $250,000.00.
Most
often, the Assistant U.S. Attorney (AUSA) will secure
a Federal Indictment from a Federal Grand Jury and
charge a defendant not only with health care fraud,
but also with mail fraud, wire fraud, money laundering,
and conspiracy to commit the aforementioned crimes.
One should also be aware that since 1987 parole
has been abolished in the Federal System. Expungement
(removal of conviction from public records) is also
not available.
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