Prosecuting and Defending Health Care Fraud Cases, Third Edition, With 2017 Supplement

This treatise provides transactional lawyers and litigators with full coverage of health care fraud, including the applicable law and the federal criminal process for health care fraud cases. It covers referral restrictions and false claims, transparency requirements for drug and device companies, rules on exclusions and penalties, major fraud settlements, and much more.


Meet The Author


A DEFINITIVE GUIDE to investigations and prosecutions in health care fraud cases 


Prosecuting and Defending Health Care Fraud Cases, Third Edition covers health care fraud from two distinct angles: the applicable law and the federal criminal process for health care fraud cases. This book analyzes trials conducted in a variety of cases, with chapters structured to match the process as it actually takes place during the investigation, after charges are brought, and through sentencing. It presents possible charges, investigative tools, proven trial strategies for both prosecution and defense, considerations for settlement of a prosecution or civil suit, and applicable sentencing factors.


The Third Edition includes: analysis of the U.S. Supreme Court decision in Escobar; a thorough review of the current state of balance between the laws and regulations regarding off-label promotion and the right to free speech set forth in the First Amendment; the addition of “substantial financial hardship” language to the Sentencing Guideline enhancement for multiple victim or mass marketing offenses; discussion of Luis v. United States and the pretrial freezing of a defendant’s assets; and more.


The 2017 Supplement includes:


  • Updated cumulative tables of health care fraud settlements exceeding $1 million, including more than 30 settlements of $100 million or more since 2010, as well as analysis of the frequency of settlements overall and in particular industry segments, by year
  • Circuit court decisions regarding the Supreme Court’s Escobar materiality requirement on false certification
  • CMS regulations on incentives for Advanced Payment Models, in part using MIPS, likely leading to future prosecutions for false claims about achieving quality measures
  • Updates to the comprehensive examination of virtually every Anti-Kickback OIG Advisory Opinion issued since 1997, including opinions on drug copayment coupon programs, providing transportation and short term lodging for patients, and more.
  • The Seventh Circuit opinion in the kickback case of U.S. v. Nagelvoort, involving hospital administrators




Part I. Introduction


Chapter 1. Introduction


Chapter 2. Litigation and Counseling: An Overview


Part II. Theories of Fraud Liability In Health Care Cases


Chapter 3. False Billing Within the Reimbursement Rules of Medicare and Key


Federal Health Care Programs


Chapter 4. The Civil False Claims Act


Chapter 5. The Federal Food, Drug, and Cosmetic Act


Part III. The Anti-Kickback Statute, Stark Prohibitions, and Anti-Kickback


Advisory Opinions


Chapter 6. The Anti-Kickback Statute and Related Safe Harbors


Chapter 7. The Stark Prohibitions and Related Safe Harbors


Chapter 8. The Anti-Kickback Advisory Opinions


Part IV. The Investigation and Charging Decision


Chapter 9. The Investigation


Chapter 10. The Charging Decision


Part V. Settlement and Litigation


Chapter 11. Global Resolutions


Chapter 12. Criminal Trial


Chapter 13. Sentencing


Appendices • Table of Cases • Index



Bloomberg BNA authors and editors are practicing professionals with insider perspectives and real-life experience. Learn more about this book’s authors and editors.
Michael K. Loucks is the former Acting U.S. Attorney and First Assistant U.S. Attorney for the District of Massachusetts. He is now a litigation partner with Skadden Arps, LLP, Boston, MA. 


View full tables of contents and read the book’s preface or introduction.