Personal Injury Made Easy

PHYSICIANS BEWARE -- HOW EVEN A FORM FILING (UNSIGNED) CAN LEAD TO FRAUD AND CRIMINAL CONVICTION

As reported by Becker: "a recent 11th Circuit Court of Appeals ruling clarified how federal prosecutors are able to charge physicians and executives for false statements in healthcare fraud cases, according to a blog post from law firm Armstrong Bradylyons.

The case involved an orthopedic surgeon who received a 33-month prison sentence for a false ownership certification on a Medicare enrollment form for the purpose of reporting a change in business hours.

Here is what physicians and ASC operators need to understand about the statute and what the case established.

1. The statute reaches beyond billing fraud
Section 1035 makes it a crime to knowingly and willfully make a materially false statement in any matter involving a healthcare benefit program. In the case, the surgeon was not charged for fraudulent billing, he was charged for a false ownership certification on a form used to report a change of business hours. The conviction stood. An administrative form filed for a non-billing purpose is still within the statute’s reach if it contains a false statement capable of influencing Medicare’s decision to allow billing.

2. A statement the form did not require can still create liability
The surgeon argued the false ownership certification could not support liability because Medicare did not require it on a change-of-hours form. The court rejected that argument. Liability under the statute does not depend on whether a statement was required, it depends on whether the defendant knowingly made a false statement that was material. A voluntary false entry carries the same exposure as a required one.

3. Physicians do not have to sign or file the form to be convicted
The surgeon did not fill in, sign or file the form but was still convicted under an aiding and abetting theory. The government proved it was his idea to list his mother as the false owner, that he supplied her identifying information, and that his co-defendant had standing authorization to sign her name. For executives and physicians whose staff handle form submissions, the ruling is a warning that authorization and involvement, even at arm’s length, can establish liability, according to the blog post.

4. Materiality is broader than most physicians assume
The court held that a false ownership statement on a change-of-hours form was material because enrollment is an ongoing relationship. This means false disclosures carry consequences on every subsequent filing, not just the initial enrollment, according to the report. The test is not whether the agency was actually misled. It is whether the false statement was capable of influencing the decision. A statement can be material even if the decisionmaker knew or should have known it was false.

5. A conviction does not automatically mean full restitution
The surgeon won on one issue: restitution. The district court ordered $315,704 in restitution, which the 11th Circuit vacated. To convict under the statute, the government needed to show only that the false statement was capable of influencing Medicare. To obtain restitution, it had to show Medicare actually relied on the statement and that reliance caused the payments. The conviction stood. The restitution order did not."

18 U.S.C. § 1035 Health Care False Statement Defense — Armstrong & Bradylyons PLLC How 18 U.S.C. § 1035 health care false statement cases work: elements, materiality, aiding and abetting, and restitution under United States v. Alexander.

Time for Fun Fact Friday!

Did you know ...

The bar-tailed Godwit might be the most extreme endurance athlete on Earth.

They can make a nonstop flight of over 7,000 miles across the Pacific Ocean from Alaska to New Zealand without landing, eating, or drinking, staying in the air for 8 to 11 straight days.

Even more incredible, it prepares by nearly doubling its body weight with fat, then shrinks its own digestive organs mid-flight to save energy. By the time it lands, it has burned through almost half its body mass, all while navigating across the open ocean using the sun, stars, and Earth's magnetic field.

Have a high-soaring weekend!

The Amazing Journey of the Bar-tailed Godwit to America's Arctic Add your voice of support here: https://www.protectthearctic.org/c...

Time for Fun Fact Friday!

Did you know chainsaws were originally invented for childbirth? 😳
Back in the late 1700s, doctors created a small hand-cranked chainsaw-like tool to help during extremely difficult deliveries long before modern C-sections existed. And somehow, that terrifying medical device eventually evolved into the chainsaws we use to cut trees today.

Even crazier: many of these procedures happened before anesthesia was widely available, meaning patients were often fully awake during this grueling process. Ouch!

So next time you hear a chainsaw, just be thankful medicine and inventions have come a very long way.

Have a “thank goodness we live in modern times” kind of weekend.

Fun Fact: Unfortunately, Chainsaws Were Invented for Childbirth | Pharmacy Times Although childbirth remains a difficult, often stressful experience for mothers, the advent of opioid medications for labor pain relief and the use of appropriate sanitation methods has made childbirth far safer for mothers than was possible during previous periods in history.