In white collar cases, including healthcare fraud, intent is one of the most critical concepts that can define a defense strategy. Facing healthcare fraud charges can be overwhelming. You need the best defense possible, which begins with understanding intent in white collar cases. Our Seattle criminal defense lawyer discusses healthcare fraud and the distinction between fraud and an honest mistake in this blog.
What Constitutes Healthcare Fraud Under Washington State and Federal Law?
Healthcare fraud is defined under Federal Code 18 USC §1347 as willfully and knowingly attempting to or executing a scheme to defraud a healthcare benefit program. Washington Code §74.09.230 also makes it a crime to knowingly make or cause to be made false statements or use deception related to medical programs.
Intent is a crucial element of healthcare fraud. It is generally required that the party knowingly and willingly engaged in a scheme or made false statements to defraud a healthcare program.
Why Intent Matters in Healthcare Fraud Prosecutions in Seattle, WA
The government must prove the defendant had a specific intent to defraud a party. Proving intent can be challenging because it requires showing what someone was thinking as they took specific actions.
Intent to defraud in a criminal case refers to an individual’s deliberate intention to cheat or deceive another party, typically with the goal of financial gain. It is a conscious effort to mislead someone by concealing information, issuing a forged document, making false statements, or creating a false impression.
Direct evidence of intent is rare, but it does happen. For example, the prosecution may have a recording of the defendant on which they can be heard discussing their intent to lie about a material fact. Therefore, the prosecution may use circumstantial evidence to prove a pattern of fraudulent conduct. For example, they may use evidence proving the defendant concealed material facts or had a financial incentive to make false statements.
The “knowingly and willingly” requirements mean that the prosecution must demonstrate the defendant’s actions were not the result of a mistake, accident, recklessness, or negligence. They knew what they were doing was wrong.
There is a difference between reckless conduct and willful misconduct. Reckless behavior is conduct that is so careless it constitutes an extreme departure from the care a reasonable person would use. Willful misconduct means taking action intentionally to achieve a wrongful purpose.
Common Scenarios That Lead to Criminal Investigations in Seattle, WA
Numerous parties can be involved in healthcare fraud, including doctors, patients, billing services, medical facilities, dentists, health insurers, fake labs, and many others. Examples of activities that could result in criminal charges for healthcare fraud include, but are not limited to:
- Billing for services not rendered
- Unbundling – billing for each stage of a procedure as if it were a separate procedure
- Providers waiving co-pays and then overbilling insurance companies
- Upcoding – billing for more expensive services than the patient required
- Billing for non-existent services or supplies, including creating fake labs and facilities for billing
- Falsifying diagnoses to justify unnecessary procedures
- Altering medical records
- Submitting multiple claims for the same service (i.e., double billing)
- Performing unnecessary procedures or treatments
Audits and whistleblower tips can trigger investigations for healthcare fraud. Additionally, federal task forces in the Seattle area, including the Health Care Fraud Prevention and Enforcement Action Team (HEAT), also help uncover cases of healthcare fraud.
Legal Strategies to Challenge Accusations of Healthcare Fraud
The state has the burden of proving its case against you. However, that does not mean you should not mount a vigorous defense against the charges. Our criminal defense lawyers challenge the state’s evidence to attack the elements of the crime, including intent.
For instance, attorneys might present evidence of the use of compliant auditing programs to establish a lack of intent. They may use evidence to prove that errors in coding and billing were a mistake instead of fraud.
Get Help from a Seattle Healthcare Fraud Defense Lawyer
The earlier you seek legal advice about the charges you face, the better for your defense. Early legal representation can prevent an investigation or inquiry from escalating into an indictment.
Attorney Jennifer Horwitz has more than 30 years of experience in criminal law. She is a seasoned trial attorney and a skilled negotiator. Contact Jennifer Horwitz Law to schedule a consultation with a Seattle criminal defense attorney.