NCJ Number
139192
Journal
FBI Law Enforcement Bulletin Volume: 61 Issue: 10 Dated: (October 1992) Pages: 8-12
Date Published
1992
Length
5 pages
Annotation
Based on a case study of Medicare fraud (the Osmomedic case), this article provides guidelines for the investigation and prosecution of health care fraud that involves charges for services and equipment that are not medically necessary.
Abstract
One key to a successful prosecution of a medical- necessity case is an understanding of the technology and medical conditions involved. The investigation should identify how the suspects misused or ignored a crucial requirement of the technology involved. The investigation and prosecution should avoid confrontations of medical experts by using a "conscious-disregard" theory rather than one of outright "no medical necessity." Suspects should be targeted from many directions. This can include calling beneficiaries to the stand, demonstrating patterns of abuse by introducing charts that summarize the physicians' own medical records, having experts explain the technology, and asking witnesses for their expert opinions as to the presence or lack of medical necessity. The investigation and prosecution should also search for and exploit minor, but clear-cut offenses. Offenses too minor to prosecute by themselves can help in the context of a medical necessity case. These offenses can convince a jury that the suspects exhibited the fraudulent intent necessary for a finding of guilt on the overall scheme.