medicare-medicaid-fraud-caseIf you’re an attorney handling government health insurance fraud cases, you may be familiar with the hefty fines the government recovers in these cases – some totaling $4.1 billion in 2011 alone.

The Medicare/Medicaid fraud case can be broken into three types or stages:  (1) a compliance failure that could pivot into litigation; (2) public aspects of changes, settlements, and verdicts against companies in fraud cases; and, (3) the fraud trial.  It is possible that the physician or medical group utilizes a different lawyer at each stage.  We can associate a potentially different expert witness for each stage, as well.


Compliance failure applies to in house counsel or a firm that has been on retainer while working with the healthcare provider for a variety of compliance issues.  An issue may arise within the healthcare setting that leads the provider to consult with counsel. Counsel will then bring in a healthcare expert witness to discuss issues, conduct an independent audit, or make and execute recommendations for remediation.

In the medical fraud matters, the Department of Justice may be conducting a formal investigation, issue charges during a press conference, or it could be announcing a favorable settlement.  We can split this piece into a public relations crisis management focus. Counsel might bring in an expert witness in Medicare/Medicaid fraud to help the lawyers not only reframe the events but understand the potential impact for on-going participation in government-sponsored healthcare reimbursement programs.

A medical fraud trial revolves around a standard litigation-based approach. Trial counsel brings in an expert witness as part of the defense testimony.  Topics the expert witness might cover in a Medicare/Medicaid fraud trial include reasonableness of care, medical record documentation of treatment decisions and treatment provided, coding or billing the treatment provided, and any error or overpayment corrections.

The cost is staggering to the medical provider facing fraud charges related to federal health care reimbursement coverage.  There is a possibility of incarceration, fine, and the termination from eligibility to participate in such programs in the future.  In short, a medical provider can be effectively shut down as a result of a finding or settlement of fraud against a Medicare/Medicaid.

For the Medicare/Medicaid fraud case, the prescription is to get the expert witness involved and involved early.  Don’t let your provider code in the courtroom.

By Paloma Capanna, J.D.