Falsifying Medical Records Defense Lawyer

Falsifying Medical Records Defense

Accuracy in medical records is not just fundamental; it's the cornerstone of the integrity, transparency, and functionality of the healthcare system. These records are not just data; they guide patient care, inform medical decisions, and serve as the foundation for billing and compliance processes.

Falsifying medical records can result in civil penalties or criminal charges under the False Claims Act or healthcare fraud laws.

Falsifying medical records is a serious offense with legal ramifications under both federal and state laws. Federal law, 18 U.S. Code § 1035, prohibits knowingly and willfully falsifying, concealing, or making materially false statements in connection with health care matters.

Violations can result in significant fines and imprisonment. Additionally, the False Claims Act (FCA) can be applied when falsified records are used to secure improper payments from government healthcare programs, such as Medicare or Medicaid.

The Health Insurance Portability and Accountability Act (HIPAA) safeguards your clients' protected health information (PHI). Altering medical records violates HIPAA's Privacy Rule, which mandates accurate and complete documentation.

Medicaid investigations may take months or even years, depending on the case's complexity, the amount of evidence, and whether they are conducted at the state or federal level.

Intentional or Unintentional Act?

An intentional falsification of medical records happens when a doctor, attorney, or patient purposely changes information to deceive courts or insurance companies.

Unintentional falsification occurs due to accidental errors, miscommunication, or flaws in the record-keeping process. It's essential to recognize that attorneys can make this mistake when collecting and organizing sensitive health information for a case.

Both physical and electronic health records (EHRs) are prone to falsification. Some common examples of falsification include:

Altering dates to cover up mistakes in treatment timelines.
Adding false information about treatments that never occurred.
Omitting critical details about a patient's condition or medical history.
Modifying test results to manipulate patient outcomes or avoid liability.

Regardless of intent, both types of falsification carry significant legal implications. Deliberately falsifying information can result in criminal charges, civil lawsuits, or fines. Healthcare fraud laws include falsification of medical records.

When medical records are deliberately falsified, it not only undermines trust in the healthcare system but can also cause harm to patients and defraud government programs or private insurers.

For these reasons, the government takes allegations of falsifying medical records very seriously. The consequences can be harsh, ranging from crippling fines to years of imprisonment.

Elements of Falsifying Medical Records

To prove a charge of falsifying medical records, prosecutors typically must establish specific elements, depending on the statute being used to bring the charges. Typically, however, prosecutors must prove the following:

Creation or Alteration of Records - You knowingly created or intentionally altered the medical records in question. This could involve forging entries, modifying existing documentation, or omitting pertinent information.
Intent to Deceive - It is not enough for a mistake or clerical error to exist. Intent to deceive or mislead must be present. This could indicate an intent to misrepresent information to secure unauthorized financial reimbursements or manipulate outcomes for the purpose of malpractice defense.
Harm or Potential Harm - The act must carry implications for a person, organization, or governmental entity. This could result in financial harm due to fraudulent billing or harm to patients caused by altered or incomplete health records.

Whether the allegations involve minor inaccuracies or more significant fraudulent schemes, cases often hinge upon proving intentional misconduct versus negligent errors or misunderstanding.

There are several laws under which individuals or organizations can be charged, depending on the circumstances surrounding the alleged falsifications. Below are some of the most notable statutes federal prosecutors often utilize.

False Claims Act (FCA)

The FCA is one of the government's most powerful tools for combating fraud by prohibiting the submission of false or fraudulent claims for payment to federal healthcare programs, such as Medicare or Medicaid.

Falsifying medical records to justify billing for services not rendered services billed at higher rates than warranted-can trigger charges under this statute.

18 U.S.C. § 287 is a provision designed to make it a fraud crime for anyone who attempts to obtain money, goods, or services from the government through various departments and agencies by presenting a false, fictitious, or fraudulent claim. It's a common tool for federal prosecutors in health care fraud and Stark law-related cases.

Forgery (18 U.S.C. § 471)

Falsifications involving the creation, alteration, or forgery of official medical documents may also fall under the statute governing forgery.

This law prohibits the creation, use, or distribution of documents intended to deceive or defraud, especially when they have a legal bearing. Convictions under this statute can result in heavy fines and imprisonment.

Healthcare Fraud (18 U.S.C. § 1347)

Healthcare fraud charges apply when false statements in medical records are used to obtain money or property from healthcare benefit programs.

Whether through the fraudulent documentation of diagnoses, fabrication of patient care records, or other alterations of files for personal or institutional gain, these actions are aggressively prosecuted under this law.

Penalties include up to 10 years of imprisonment, with more severe consequences if the fraud results in bodily harm to a patient or other individuals.

18 U.S. Code § 1347 - Health care fraud says, "(a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice-

(1) to defraud any health care benefit program; or

(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both.

If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or life, or both."

Under 18 U.S.C. § 1347, charges of health care fraud involving medically unnecessary procedures can result in up to ten years in federal prison per count, with no maximum if the patient was seriously harmed.

Under 18 U.S.C. § 1349, merely agreeing to participate in a scheme to defraud a federal health benefit program is a crime known as a healthcare fraud conspiracy.

Common Legal Defenses to Falsifying Medical Records

If you're facing federal criminal charges in connection with allegations of falsifying medical records, working with an experienced federal criminal defense attorney is essential to navigating your way through these charges. Below are some standard defense strategies that a skilled attorney may employ, including the following:

Lack of Intent. One of the most critical elements prosecutors must prove is intent. Without evidence showing deliberate falsification or an intention to deceive, the government may not secure a conviction. Many cases of alleged falsification arise from misunderstandings, confusion regarding documentation standards, or simple clerical errors, none of which constitute criminal intent.
Mistake or Accident. Medical records are often lengthy and highly detailed. Simple mistakes in data entry or record-keeping are inevitable in such complex environments. A defense may focus on demonstrating that errors were unintentional and do not meet the threshold of willfulness required for criminal prosecution.
Lack of Impact Demonstrated. Certain cases hinge on proving the harm or impact caused by alleged falsifications. Without clear evidence of financial loss or adverse patient outcomes, a defense may argue that no substantive harm occurred, undermining the justification for prosecution.
Constitutional Violations. Investigations into falsified medical records can involve audits, subpoenas, or raids. If law enforcement or regulatory bodies violate Fourth Amendment protections against unreasonable search and seizure, evidence collected unlawfully may be excluded from proceedings. This could significantly weaken the government's case.

For more information, contact our federal criminal defense law firm, Eisner Gorin LLP, located in Los Angeles, CA.

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