Health Care Fraud – What the Government Must Prove

Health Care Fraud is one of the most common white collar crimes charged by the Federal Government. The Health Care Fraud statute states:

(a)Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice—

(1) to defraud any health care benefit program; or

(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program,in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.

(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section. 18 U.S. Code § 1347. Health care fraud

In order to be found guilty of health care fraud, the government must prove beyond a reasonable doubt that the defendant participated in a scheme to defraud a federal health care benefits program. The government must also prove beyond a reasonable doubt that the defendant “knowingly and willfully” carried out the scheme, that the defendant “acted with the intent to defraud” and that the scheme “involved a materially false . . . representation.” Intent to defraud requires a specific intent to “deceive or mislead.” [i] Thus the government must prove that the defendant had the specific intent to defraud and acted knowingly with the intent to cheat the government. [ii]

The health care fraud statute also requires that the false representation be material and the Supreme Court has defined materiality in federal fraud statutes as follows: “[T]he term ‘material’ means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.” [iii] This materiality requirement descends from “common-law antecedents.” [iv] Indeed, “the common law could not have conceived of ‘fraud’ without proof of materiality.” [v]

A representation is material if it is capable of influencing the decision of the person to whom it is addressed. A matter is material if a reasonable person would think it important or if the defendant knew that the victim thought it was important even if it was unreasonable. The Supreme Court in Universal Health Services v. United States ex rel. Escobar went on to state that “The materiality standard is demanding.” [vi]

If you are being investigated or have been charged with health care fraud or a related offense, visit Rosenblat Law or contact Mike Rosenblat at 847-480-2390.

The information and articles on this web site are for general information only and are not intended and should not be taken as legal advice.

[i] United States v. Natale, 719 F.3d 719, 741-42 (7th Cir. 2013).

[ii] U.S. v. Natale, 719 F.3d 719, 741 (7th Cir. 2013), citing and quoting, “[United States v.] Awad, 551 F.3d 930, 940 (9th Cir. 2009) (noting jury was instructed in § 1347 prosecution that “‘intent to defraud’ [is] defined as ‘an intent to deceive or cheat’ ”); United States v. Choiniere, 517 F.3d 967, 972 (7th Cir. 2008) (noting jury instruction in § 1347 case defined “‘intent to defraud’ to mean ‘that the acts charged were done knowingly with the intent to deceive or cheat the victims’”); United States v. White, 492 F.3d 380, 393–94 (6th Cir.2007) (to convict under § 1347 “the government must prove the defendant’s ‘specific intent to deceive or defraud’”)”.

[iii] See Neder, 527 U.S., at 16, 119 S.Ct. 1827 (using this definition to interpret the mail, bank, and wire fraud statutes); Kungys v. United States, 485 U.S. 759, 770, 108 S.Ct. 1537, 99 L.Ed.2d 839 (1988) (regarding fraudulent statements to immigration officials).

[iv] Id., at 769, 108 S.Ct. 1537.

[v] Neder, supra, at 22, 119 S.Ct. 1827;” Universal Health Services, Inc. v. U.S., 136 S. Ct. 1989, 2002 (2016)

[vi] 136 S. Ct. 1989, 2002-03 (2016).