Benefits Fraud

The massive influx of pandemic relief funds led to a crackdown on unemployment insurance fraud. Prosecutors are aggressively pursuing individuals who claimed benefits while working or who applied in multiple states.

We defend against these charges by examining the chaotic nature of the application systems during the pandemic. Many legitimate claimants were given conflicting advice by overwhelmed agency staff. 

Common defense arguments include:

• Reliance on official guidance that later changed
• Identity theft where third parties filed claims in the client's name
• Confusion regarding eligibility criteria for gig economy workers
• Administrative errors by the state agency in calculating benefit amounts

Benefits fraud in the healthcare sector often targets providers who bill for services not rendered or who upcode procedures to receive higher reimbursements. These cases are technically complex and rely on statistical sampling.

We challenge the government's audit methodology. We employ medical billing experts to review the patient files and prove that the services billed were medically necessary and accurately coded. We argue that a billing dispute is a contract issue between the provider and the insurer rather than a criminal act. By validating the medical necessity of the treatment, we undermine the prosecution's claim that the government was defrauded.

Not every lie supports a fraud conviction. The falsehood must be material meaning it had the natural tendency to influence the government's decision to pay. We challenge the materiality of the alleged misrepresentation.

If a client failed to report a small side income but that income was below the threshold that would reduce their benefits, the failure to report is immaterial to the payment decision. We argue that because the government would have paid the same amount anyway, no fraud occurred. This technical defense can lead to the dismissal of charges even if the application contained errors.

Prosecutors often charge entire families or groups of employees with conspiracy to commit benefits fraud. This allows them to hold one person responsible for the actions of others.

We fight to sever our client's case from co-defendants. We argue that our client had a limited understanding of the scheme or was manipulated by a dominant figure. In domestic cases, we often show that one spouse handled all financial paperwork and the other spouse signed forms without reading them. This lack of knowledge defense protects the passive spouse from being held criminally liable for the partner's deceit.

The government often argues for sentencing based on intended loss (the amount the defendant tried to steal) rather than actual loss (the amount the government paid). We fight to limit the loss amount to the actual overpayment.

We perform a forensic accounting of the benefits. We argue that the client was legitimately entitled to a base level of benefits and that the fraud only applies to the surplus. By reducing the loss amount from the total payout to the specific overpayment, we can significantly reduce the sentencing exposure. We also argue for credits against the loss for any value provided by the defendant (such as legitimate medical services).

Beyond prison and fines, a conviction carries devastating collateral consequences. Healthcare providers face exclusion from Medicare and Medicaid (effectively ending their careers). Individuals may lose eligibility for future public housing or food assistance.

We negotiate resolutions that attempt to preserve eligibility or limit the period of debarment. In some cases, we can structure a civil settlement that avoids a criminal conviction entirely. This allows the professional to retain their license and continue practicing while repaying the government over time.

The most powerful defense in fraud cases is good faith. If the defendant honestly believed they were eligible for the benefits, they cannot be convicted of fraud.

We gather evidence of the client's state of mind. This includes emails to agency caseworkers asking for clarification, notes from phone calls with help lines or reliance on the advice of tax professionals. We argue that the complex bureaucracy of the benefits system led to an honest mistake. We present the client as a confused citizen trying to navigate a broken system rather than a predator exploiting it.

In the digital age, many benefits fraud cases involve identity theft. Criminal rings use stolen social security numbers to file false claims. The victim often learns of the fraud only when they receive a tax form for benefits they never received.

We prove that our client was the victim, not the perpetrator. We trace the IP addresses used to file the claims to show they originated from outside the client's home. We analyze bank records to show the funds were deposited into accounts the client did not control. By proving the client never received the money, we exonerate them from the crime.

Investigations often start with a whistleblower (known as a relator) filing a qui tam lawsuit. This is common in healthcare and government contracting. The whistleblower receives a portion of the recovery.

We investigate the motivation of the whistleblower. Often they are disgruntled former employees with an axe to grind. We challenge their credibility and their version of events. We also argue that the government had prior knowledge of the practices and continued to pay the claims which can serve as a defense against the False Claims Act allegation.

When liability is clear, we focus on damage control. We negotiate settlement agreements that allow the client to pay restitution over time without admitting liability.

We emphasize the client's ability to pay. There is no benefit to the government in bankrupting a provider or an individual. We present financial disclosures to prove that a lower settlement amount is the maximum feasible recovery. We structure these settlements to avoid triggering automatic debarment provisions whenever possible (protecting the client's future livelihood).