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Health Care Fraud: A Federal Offense

Health Care Fraud (18 U.S.C. Section 1347)

To support a conviction for health care fraud under 18 U.S.C. Section 1347, the government must prove that the defendant: (1) knowingly and willfully executed, or attempted to execute, a scheme to (2) defraud a health care program, here, as set out in the superseding indictment, the Medicare program, or to obtain by false or fraudulent pretenses money or property under the custody or control of a healthcare program, (3) “in connection with the delivery of or payment for health care benefits, items, or services.” 18 U.S.C. Section 1347. Also, the government must show that the defendant’s scheme to defraud affected interstate commerce. (For a defendant to commit health care fraud, he or she must know that the claims submitted are, in fact, false.) (In a prosecution for Medicaid fraud, failure to instruct the jury that it had to find that physician must either have known that Medicaid claims being submitted were false or have submitted claims with the intent to defraud or deceive was a prejudicial error; general definition of “knowingly and willfully” was not helpful.) To successfully convict a defendant of health care fraud using an aiding and abetting theory, the government must prove that the defendant: (1) “associated himself with the criminal venture”; (2) wished to bring about the criminal offense; and (3) “sought by his actions to make it succeed.” Also, to support a conviction for aiding and abetting, the government must prove, in addition to the commission of the offense by the principal, that the defendant “‘consciously shared the principal’s knowledge of the underlying criminal act, and intended to help the principal.” Finally, with regard to aiding and abetting, while the defendant need not know all parts of the alleged scheme and crime, he or she must have enough knowledge to establish the necessary scienter, and the government must do more than show that the defendant participated in a transaction that turned out to be part of a fraudulent scheme. Instead, the government must also show that the defendant willfully participated in the scheme with knowledge of its fraudulent nature and with the intent that the illicit objectives be achieved.

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