Health Care Fraud

United States v. Rufai, 732 F.3d 1175 (10th Cir. 2013)

While the defendant’s conduct aided the principal’s health care fraud offense, the evidence was insufficient to show that the defendant was aware of the crime and thus he could not be convicted of aiding and abetting the health care fraud crime. Innocent explanations for his conduct were too reasonable to allow the government to convict based on alternative theories that supported the argument that he “must have known” about the principal’s crime.

United States v. Medina, 485 F.3d 1291 (11th Cir. 2007)

It is a federal crime to solicit or pay kickbacks in connection with certain health care related transactions. For example, a medical equipment supplier may not pay a kickback to a patient or a doctor to use his equipment that is covered by Medicare. 42 U.S.C. § 1320a-7b(b)(2)(A). Every violation of this anti-kickback provision, however, does not amount to health care fraud under 18 U.S.C. § 1347. Fraud requires proof of a false statement or some other kind of fraud. In this case, the court reversed the health care fraud convictions of most of the defendants because their kickback violations were not accompanied with any fraudulent conduct. The equipment was, in fact, supplied and Medicare was not over-billed. One defendant, however, submitted a form that falsely stated that she complied with all Medicare rules (including the anti-kickback provision) when she knew that she was violating that provision. Her fraud conviction was sustained.

United States v. Jones, 471 F.3d 478 (3rd Cir. 2006)

The defendant was a clerk at a methadone clinic. She stole cash from the clinic that was paid by patients. This does not constitute a § 1347 offense, because the theft did not amount to “fraud.” The defendant made no “misrepresentations by the employee in connection with the delivery of, or payment for, health care benefits, items, or services.”

United States v. Miles, 360 F.3d 472 (5th Cir. 2004)

The defendants paid a public relations firm to deliver literature and business cards to local medical offices. The firm was paid a set amount for each Medicare patient who became a client of the defendant’s company as a result of the firm’s work. This did not violate 42 U.S.C. § 1320a-7b(b)(2)(A). Because the public relations firm did not “refer” patients to the defendant’s company, the statute did not apply.

United States v. Starks, 157 F.3d 833 (11th Cir. 1998)

The defendant was charged with violation of the Medicare Antikickback Statute, 42 U.S.C. § 1320a-7b(b). The court concluded that the “willful” requirement was properly explained to the jury in these terms: “The word “willfully,” as that term is used from time to time in these instructions, means the act was committed voluntarily and purposely, with the specific intent to do something the law forbids, that is with a bad purpose, either to disobey or disregard the law.” The defendant sought a “Ratzlaf” instruction that would have required the jury to find that the defendant was aware of the actual law he was violating. Based on Bryan v. United States, 118 S. Ct. 1939 (1998), however, the court concluded that the government was only required to prove that the defendant was aware that he was violating the law – not that he was aware of the specific law that he was violating.