Recently, the U.S. Attorney’s Office for the Northern District of Illinois announced the creation of a new section of the Criminal Division focused on the prosecution of healthcare fraud. The new section will be staffed with six federal prosecutors, all based in Chicago.
According to the press release, the newly created Healthcare Fraud Section “will be tasked with prosecuting defendants in all types of healthcare fraud, such as false and fraudulent claims submitted by transnational criminal organizations to America’s health insurance programs; upcoding and unbundling schemes; scams by providers and individuals against Medicare and Medicaid; fraudulent billing; and illegal kickbacks, among many other healthcare-related frauds and schemes.” Its work will be in addition to the Chicago office’s existing Healthcare Fraud Strike Force unit, which is part of the Fraud Section of the DOJ’s Criminal Division, and with which the new Healthcare Fraud Section “will continue to closely coordinate and collaborate.”
Healthcare fraud is one of the DOJ’s key areas of focus, and this latest announcement is confirmation that federal prosecutors intend to maintain this focus going forward. Since March of 2007, the DOJ has charged more than 5,800 defendants and recovered more than $27 billion in healthcare fraud matters. The bulk of this work involves charges under the False Claims Act, which makes it illegal for private actors, such as healthcare providers and medical equipment providers, to submit for payment with government funds claims that do not meet all legal requirements. In the healthcare context, a false claim is one that is not medically necessary, unsupported by the medical record, falsely certified to be compliant with the law when it is not, or otherwise not eligible for payment.
The DOJ uses sophisticated data-mining tools and works closely with the Centers for Medicare and Medicaid Services to unearth potential healthcare fraud. In addition, the DOJ relies on whistleblowers, who are allowed a share of the recovery in the event of a successful claim under the False Claims Act. These cases often involve internal investigations and may subject a client to civil or criminal liability.
Often, the first indication that a client is under investigation for healthcare fraud is when it is served with a Civil Investigative Demand (CID) or subpoena for testimony or documents. Clients who receive such a demand should engage counsel with expertise in healthcare fraud as early as possible; it is important for clients to consult counsel before responding to the CID or subpoena.
Smith, Gambrell & Russell, LLP has a deep bench of professionals in its White Collar, Healthcare and Litigation practices who stand ready to defend clients encountering healthcare fraud issues, including James R. “Jim” Figliulo, Joel B. Bruckman, Terrence J. “T.J.” Sheahan, Thomas D. Bever, Anthony L. “Tony” Cochran, Erin N. Spritzer, and Susan C. Atkinson. Smith Gambrell has extensive experience handling healthcare fraud matters, including responding to Civil Investigative Demands and subpoenas.