Countering health care fraud charges through evidence

August 4, 2022
Countering health care fraud charges through evidence

Federal and Missouri public health care programs have strict record keeping requirements for physicians seeking reimbursement. After providing medical services to patients, a practitioner must submit claims to the government to receive payment. 

According to Johns Hopkins Medicine, a common health care fraud charge involves misrepresenting medical services to receive a larger payment. Doctors may find themselves facing fraud charges from allegations of treating nonexistent medical conditions. Suspicions of falsified surgeries or procedures may lead to accusations of untruthful billing practices. 

Fighting a charge with accounting and medical records 

When a practitioner allegedly filed a false claim, a prosecutor must prove beyond a reasonable doubt that he or she intended to deceive an insurance provider. Submitting claims recklessly or without regard to the truth, however, may indicate negligence rather than dishonesty. 

Disclosing accounting and billing records could demonstrate an error or mistake on the part of the doctor or staff member. A physician may also counter a fraud charge by providing detailed performance records or other proof of the services performed. The files of patients who required treatment could coincide with a doctor’s hospital schedule. 

Asking witnesses to testify that services were necessary 

Possible witnesses who could verify medical services as necessary procedures include nurses, staff or other practitioners who assisted with a treatment. Patients may also testify to confirm their identities, conditions and health care regimen. Various testimonies could show that a doctor submitted bills honestly and in good faith. 

Bargaining when evidence does not provide an adequate defense 

As noted by the American Bar Association, accepting a plea bargain preserves the court’s resources and may result in a more lenient sentence in many cases. Plea bargaining allows a physician to come to an agreement with a prosecutor to resolve a case that the available evidence cannot counter. 

A fraud charge may not always lead to a felony conviction. While an experienced prosecutor may accept a plea deal, however, a federal judge must also approve it. Although the judge may need to meet minimum sentencing guidelines, under certain circumstances, the sentence may not require incarceration. 


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