By Subodh Chandra
My experience in addressing healthcare-fraud cases arises from my service as a federal prosecutor in the United States Department of Justice. In the U.S. Attorney's Office for the Northern District of Ohio, I was assigned specifically to oversee the investigations of and prosecute healthcare-fraud cases. I also served on a multi-agency, multi-governmental Healthcare Fraud Task Force that included representatives of the FBI, U.S. Department of Health & Human Services Office of Inspector General, State Medical Board of Ohio, Ohio Attorney General’s Office, and others.
My years at the Justice Department prosecuting allegations of healthcare fraud including pursuing significant violations of the federal anti-kickback statute, 42 U.S.C. § 1320a-7b(b); the healthcare-fraud statute, 18 U.S.C. § 1347; and the mail-fraud and wire-fraud statutes.
Many of my healthcare-fraud and other federal criminal prosecutions resulted in guilty pleas, following extensive negotiations, while others went to trial, resulting in convictions.
These experiences have given me significant insight into how federal prosecutors put together healthcare-fraud cases, starting when an FBI agent or a representative of the Office of Inspector General of the US Department of Health & Human Services comes to the prosecutor suggesting there is a healthcare-fraud allegation worth investigating. I know how to evaluate the case and determine whether it's something that the federal government would be extremely interested, moderately interested, or not interested in pursuing. Because I handled the federal criminal prosecutions for healthcare fraud, I’m also experienced with how they put the case together, what kind of evidence is needed, and what kinds of evidence would defeat a potential claim of healthcare fraud.
I’ve also worked with the U.S. Department of Justice attorneys responsible for affirmative civil enforcement. Their job is to handle those healthcare-fraud cases that are serious enough that the Department of Justice requires a representative to track and recover money on behalf of the U.S. government but not sufficiently serious that criminal charges are filed. Those attorneys work in parallel with federal prosecutors, or the investigations often happen in parallel with the criminal prosecutor taking the lead.
Because I worked with them, I have a sense of what they are looking for: what minimum dollar thresholds they're interested in before they will pursue a False Claims Act case, what types of alleged schemes interest them most, and what types of alleged offenses are too hard to prove.
In the course of my work as a federal prosecutor, I secured dozens of convictions of individuals and companies for healthcare-fraud schemes. I received special recognition from FBI director Robert S. Mueller, III for “demonstrated excellence” in a series prosecutions for healthcare fraud and violations of the anti-kickback statute.
It's a deep well of experience that our office now uses in different types of cases.
Here are the types of people that we represent. Individuals or company owners who are being investigated for healthcare fraud or variations of healthcare fraud like mail fraud, wire fraud, conspiracy, or aiding and abetting healthcare fraud.
Sometimes, we represent individuals who had other representation but a trial is approaching and they want an attorney who is not afraid to try a case. Some clients were represented by other attorneys, were convicted, and want to appeal—or the prosecutors are pursuing other healthcare-fraud convictions or a conviction on multiple counts. Sometimes, it’s someone who has been convicted and already been through an appeal but wants to bring a claim for ineffective assistance of counsel or what is known as a “collateral attack” on the conviction following the direct appeal process.
We also represent people who believe they have found a fraud scheme that would be valuable to the government itself. These might be individuals thinking about bringing a False Claims Act case on behalf of the United States government. A private party has come to us believing that there is a significant healthcare-fraud issue that is of concern to them., with significant potential losses. The individuals who come to us ready to blow the whistle on healthcare fraud are often either current employees or former employees. Sometimes, these are people who have come to know about fraud through some other means. We help analyze and understand whether this is something that might interest the federal government where fraud is involved with government money through the Medicare, Medicaid, Tricare programs, or the Veterans Administration.
We work with individuals who are thinking about blowing the whistle to help them understand if they have a good case. Then we help them develop a draft disclosure statement required under the False Claims Act to go to the government, give them a preview of what it is that we're about to file, and file the complaint with the government to launch the initial investigation to determine if there is a fraud.
Finally, sometimes entities want us to do an internal investigation to see whether healthcare fraud occurred. That might be a corporation or it might be a private practice.