A medical practitioner facing charges of health care fraud may worry about beating a robust prosecutorial team. The government has extensive resources but may rely on general data when debating the necessity of a claim or procedure.
One way a nurse or physician can bolster their case is to call on authoritative witnesses with experience to show that an action was reasonable.
Reasons for fraud charges
A suspected false claim to a third-party insurer or government-run health care benefit program may raise a charge of health care fraud. The government wins the case if it can prove beyond a reasonable doubt that the defendant devised and completed a scheme to defraud a health care benefit program.
Common forms of health care fraud include the following:
- Providing false statements on contracts or applications for Medicaid and Medicare programs
- Performing medically unnecessary services solely to generate insurance payments
- Billing for more expensive procedures, equipment or services than one provided
- Submitting false claims or inflated claims
- Accepting kickbacks for referrals
Penalties can reach up to 20 years in prison and include fines.
Who can be an authoritative witness?
Federal Rule of Evidence 702 states that a witness who is a credible professional by knowledge, skill, experience, training or education can provide valid testimony at a trial. Such professionals can help in complicated matters of billing and coding. Professionals with certifications in regulatory compliance can also assist a defendant by enlightening the judge or jury on variables and unique factors to the case.
Medical issues are intricate, which is why practitioners dedicate years to mastering their profession. If the authorities question a medical professional’s actions, an outside source may help clarify matters.
