2. Chapter 4
Criminal Aspects of Health
Care
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3. Baltimore County woman who bilked friends for fake
cancer treatments to be sentenced. After seeking
money from friends, Leone pleaded guilty to felony
theft The message sounded desperate.
"I need to raise $1,900 before the end of the night," it
said. "My medical bills and everything has totally put us
in the poor house. … I want to live and I want to stop
losing stuff just because of this cancer.‖
The Facebook plea was from Dina Perouty Leone, who at
the time, in June 2009, "was asking everyone and their
brother for money," according to the message's
recipient, Maurica Marcum, a former classmate of
Leone's at Sparrows Point High School.
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4. Continued
"I never would ask anyone or want others to know our
business, so please don't tell anyone," Leone continued in her
message. "I am just lost.― In fact, Leone had been seeking
money from friends and acquaintances for months, prosecutors
said, ostensibly to help her pay for treatment of terminal
stomach cancer. As far back as October 2004, she wrote an
Internet posting saying she had been fighting the disease for
"over a year and a half" — only that time it was breast cancer.
Later, she said she'd had cervical cancer for a decade. None of
it was true.
October 27, 2010, By Nick Madigan, The Baltimore Sun

5. Between a Rock and A Hard Place
Baltimore Woman Accused of Raising Money for
Cancer Victim and Then Keeping It . . . Rock is
accused of one of the lowest possible crimes: raising
money for a 5-year-old girl with cancer and then
keeping the money for herself.
February 1, 2010
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6. Lawyers see St. Joseph's stent claims
growing
. . . Frank Ward . . . went to St. Joseph Medical
Center for a heart procedure, Dr. Mark Midei put a
stent in his artery after finding a blockage, and now
another doctor says the blockage was insignificant
and the stent wasn't necessary. A total of 585 patients
have received letters from St. Joseph describing
similar scenarios, after the Towson hospital reviewed
the last two years of Midei's cases.
Robert Little, The Baltimore Sun | May 22, 2010
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7. Criminal law
Criminal law (also known as penal law) is the body
of statutory and common law that deals with
crime and the legal punishment of criminal
offenses.
What is the purpose of criminal law?
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8. Purpose of Criminal Law
• Maintain Public Order & Safety
• Protect Individuals
• Punishment as a Deterrent
• Rehabilitation
What are the definitions of a crime, misdemeanor & felony?
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9. Definitions
• Crime – social harm defined & made
punishable by law.
• Misdemeanor – offense punishable by less
than 1 yr in jail and/or a fine.
• Felony – imprisonment in a state or federal
prison for more than a year.
What is an arraignment?
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10. Arrest & Arraignment
• Formal reading of the accusatory instrument
– a generic term that describes a variety of
documents, each of which accuses a defendant of
an offense
• includes the setting of bail
What is the purpose of a conference with the
defendant and prosecutor?
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11. Conference
• Meeting for purposes of deliberation
• Plea bargaining time
• Commences with the goal of an agreed-upon
disposition
– If no disposition can be reached, a case may be
assigned to a trial court.
Describe the process of conducting a criminal trial?
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12. Criminal Trial – I
• Jury selection
• Opening statements
• Presentation of witnesses & evidence
– Standard of proof must be beyond a reasonable
doubt.
• Summations
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13. Criminal Trial – II
• Instructions to the jury by the judge
• Jury deliberations
• Verdict
– must be unanimous decision
• Opportunity for appeal
What does the false claims Act of 1986 prohibit?
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14. False Claims
• False Claims Act of 1986
– Knowingly presenting a false claim for
payment.
– making a false record to get a false claim paid.
– conspiring to defraud the government.
– making a false record to avoid an obligation to
pay or transmit property to the government.
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15. Kickbacks
• Laboratory
• Architectural Contract
• Ambulance Service
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16. Health Care Fraud
HIPAA
• Congress passed HIPAA in 1996.
• Provides criminal & civil enforcement tools &
funding to fight health care fraud.
• HIPAA requires U.S. AG & Sectry of DHHS acting
through OIG to establish coordinated national Health
Care Fraud & Abuse Control Program.
• Program provides coordinated national framework for
federal, state, & local law enforcement agencies; the
private sector; & public to fight health care fraud.
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17. Schemes to Defraud
• Need to establish:
• Defendant engaged in a scheme constituting a
systemic course of conduct
• Defendant did so with the intent to defraud
more than one person
• Defendant obtained property from one or more
persons, at least one of whom has been
identified
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18. Prevention of Fraud - I
1. Develop policies & procedures
2. Set-up a corporate compliance program
3. Communicate organization’s
compliance program to employees
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19. Prevention of Fraud - II
4. Establish monitoring & auditing systems for
detecting fraud
5. Publicize a reporting system for reporting
criminal conduct
6. Respond to criminal conduct
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20. Prevention of Fraud - III
7. Periodically review & update the
compliance program
8. Cooperate with state & federal
law, enforcement, & regulatory agencies &
insurance companies to detect, prevent, &
prosecute fraud
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21. Fraud Cases I
• Healthy Dose of Fraud
• Home Care Fraud
• Medicare & Medicaid Fraud
• False Medicaid Claims
• Fraudulent Billing for Laboratory Tests
• Physician Bills for Services Not Rendered
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22. Fraud Cases II
• Pharmacist Submits False Drug Claims
• Inaccurate Records & Controlled Drugs
• Nursing Facility Stockholder Falsifies Records
• Inflating Insurance Claims
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23. Fraud and Ethics
• Behind every Healthcare Fraud is a LACK OF
ETHICAL BEHAVIOR
• Unethical Pay to Referring Physicians
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24. Falsification of Records
• Falsification of medical & business records is
grounds for criminal prosecution.
• Anyone who suffers damage as a result of
falsification of records may claim civil
liability.
• The provider could lose Medicare & Medicaid
funding.
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25. False Entries in Operative Report
When a surgeon omitted a true entry in his
operative report by not indicating that a
nonphysician assisted in a patient’s surgery,
the surgeon was indicted for falsification of
records.
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26. The Toxic Pharmacist
Two months before his arrest . . . the pharmacist
who in 1990 listed his gross income as
$48,000 had amassed $18.7 million in total
assets. During approximately the same time
frame, Robert Courtney would, by law
enforcement estimates, dilute 98,000
prescriptions for 4,200 patients.
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27. Misuse & Theft of Drug Text Cases
• The Toxic Pharmacist
• Internet Pharmacy
• Conspiracy to Distribute Dilaudid
• Illegal Use and Sale of Marijuana
• Theft of Drugs
• Fraudulent Billing
• Distribution of Misbranded Drugs
• Abuse Prescribing Controlled Substances
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28. Internet Pharmacy
Customers would obtain prescription and
nonprescription drugs from the Internet
pharmacy . . . Dr. Nelson, the defendant in this
case, agreed to review the
prescriptions, approving 90% to 95% of
prescription requests without examining his
purported patients.
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29. Physicians: Victims of Fraud
• Familiarize themselves with patient-billing &
recordkeeping practices.
• Avoid having one individual in charge of
billing & collection procedures.
• Arrange for an annual audit of office
procedures & records by an outside auditor.
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30. Patient Abuse
Patient abuse is the mistreatment or neglect of
individuals who are under the care of a health
care organization.
Describe the signs of resident abuse the surveyors
look for.
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31. Granny Cams
Gale . . . wasn’t prepared for the rough treatment
and cruel taunts she says her ailing mother
suffered at the nursing home. She cried as a
nurse’s aide upbraided her mother for failing to
straighten her arthritis-stricken legs. And she
watched in disbelief as an assistant jerked her
mother off her rubber bed pad and pushed her into
the bed’s metal rails.
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32. Signs of Abuse – I
• Physician's order for restraints
• Time-limited orders
• Number of patients restrained
• Type of restraints being used
• Restraints applied correctly
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33. Signs of Abuse – II
• Condition of restrained patients
• Restraints released as required by law
• Exercise is provided for the patient
• Staff response to requests for water, assistance
to the bathroom, etc.
• Signs of mental & physical abuse
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34. Signs of Abuse – III
• Restrained patients observed by staff
• Signs of harassment, humiliation, or threats
from staff or patients
• Effect of restraints on patients
– signs of overmedication
– Frequency of overmedication
• Whether patients are comfortable with staff
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35. Signs of Abuse – IV
• Patients with bruises or other injuries
• Patient-to-patient interactions
– staff response
• Evidence of patient neglect
– patients left in urine or feces without cleaning
Describe forms of abuse
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36. Forms of Abuse
• Physical
• Psychological
• Medical
• Financial
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37. Abuse Cases - I
• Neglect of Residents
• Abuse & Revocation of License
• Abusive Search
• Physical Abuse
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38. Abuse Cases - II
• Forcible Administration of Medications
• Abuse of Stroke Patient
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39. Criminal Negligence
• Reckless disregard for the safety of others.
• Willful indifference to an injury that could
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40. Manslaughter
• Unlawful killing of another person without malice
of forethought.
• Voluntary or involuntary
– Voluntary manslaughter: intentional killing of
another person (e.g., in ―the heat of passion‖)
– Involuntary: death occurs as the result of a
negligent act.
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41. Murder
• 3 Shot at Georgia Hospital
• Nurse Sentenced for Diabolical Acts
• Fatal Injection of Pavulon
• Fatal Injection of Lidocaine
• Lethal Dose of Anesthesia
• Lethal Dose of Codeine
• Removal of Life Support Equipment
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42. Rape
• When one person is forced, without giving
consent, to have sexual intercourse with
another.
• Hospital Held Liable in Patient’s Rape
• Sexual Assault Was Foreseeable
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43. Theft
• Cost Millions Annually
• Patient Valuables
• Staff Valuables
• Supplies
• Medical Equipment
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44. Theft Cases
• Theft of Resident’s Money
• Nurse Assistant Misappropriates Resident’s
Funds
• Commingling Resident’s Personal Funds
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45. Sexual Assault
An action was filed against a nursing facility after
the plaintiff's mother was sexually assaulted by a
dementia patient. There was testimony that the
facility was properly staffed. There was testimony
that the resident suffered no physical injury & she
was not aware of the assault.
What was the Court decision?
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46. Court Decision
The court found that the facility had not
breached its duty of care.
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47. Questions - I
1. What are the objectives of criminal law?
2. Describe the difference between a
misdemeanor & a felony. Give an example of
each.
3. List the processes of a criminal trial.
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48. Questions - II
4. Why was the False Claims Act of 1986
enacted?
5. Why has health care fraud been so costly to
the nation?
6. Discuss why physicians historically have been
reluctant to remove a patient's life-support
systems.
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49. Questions - III
7. Discuss why you believe patients are
sometimes reluctant to complain about their
health care
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