The rules and process for calculating loss amount favor the government. The sentencing guidelines define “loss” as “the greater of actual loss or intended loss,” and provide that the sentencing judge “need only make a reasonable estimate of the loss.” When a judge calculates the intended loss, absolute accuracy is not required, so long as the calculation is not “outside the realm of permissible computations.”
Courts have held losses caused by the acts of co-conspirators that were reasonably foreseeable to the defendant should also be included in the loss calculation. The sentencing court should, however, limit the defendant’s liability to those acts of coconspirators that were reasonably foreseeable and part of the criminal activity that the defendant “agreed to jointly undertake.”
In a healthcare fraud case, the amount fraudulently billed to the federal insurance program (Medicare or Medicaid) is “prima facie evidence of the amount of loss [the defendant] intended to cause,” but there can be additional evidence presented by the defense to demonstrate that this total “exaggerates” the defendant’s intent.
Loss includes all relevant conduct, including charged, uncharged, and acquitted conduct and is not limited to losses directly attributable to the defendant. For example, a defendant convicted of defrauding Medicare can be held responsible for the losses not only to the Medicare program but to private insurers and patients.
Every healthcare provider knows that Medicare, Medicaid, and private insurance companies do not actually pay the amount billed. Usually it is some lesser amount.
Under no circumstances should someone facing healthcare fraud charges accept the government’s recitation of the loss amount. The government’s loss number is generally inflated and created using poor methodology.
But a well-skilled healthcare fraud defense attorney — the kind you will find at Chapman Law Group — will know other strategies useful for determining a lower loss amount, such as claim sampling and extrapolation.
As an example, let’s say a pharmacist fraudulently billed Medicare for reimbursement of prescriptions for non-existent patients. If the government claims the loss to the Medicare program was at least $1 million but less than $1.5 million, the potential prison sentence could be 30 to 37 months.
But, if by aggressively investigating the case data, a healthcare fraud attorney from Chapman Law Group can show the loss to the Medicare program was actually less than $550,000, the potential prison sentence can be substantially lowered to 18 to 24 months.
Once that is accomplished, our team can work towards getting the final sentence recommendation to a level that can be non-prison.
This scenario is precisely why you need a dedicated Miami fraud defense attorney to defend your Medicare or Medicaid fraud case.
This is why you need the Miami health care fraud defense attorneys from Chapman Law Group.