United States v. Paulus — Mar. 2017 (Summary)

HEALTH CARE FRAUD

United States v. Paulus
No. 15-15-DLB-EBA (E.D. Ky. Mar. 7, 2017)

The United States District Court for the Eastern District of Kentucky granted a physician’s motion for acquittal and conditionally granted the physician’s motion for a new trial regarding his criminal conviction on health care fraud and false statements.

The physician allegedly performed unnecessary cardiac stents and misstated the severity of stenosis in medical records to retroactively justify the procedures.  The physician was indicted by a grand jury and was later convicted of committing health care fraud and making false statements relating to health care matters.  The physician asked the trial court to overturn the conviction, claiming that there was insufficient evidence for a reasonable jury to conclude that he devised a scheme to defraud a health care benefit program or that he knowingly and willfully made objectively false statements.

The court reviewed the government’s evidence to determine if it was sufficient to enable the jury to determine that the physician’s statements regarding his patients’ medical conditions were false beyond a reasonable doubt.  The government argued that  the physician’s profits, patient volume, and testimony of coworkers and patients were circumstantial evidence of falsity while offering expert opinions that contradicted the physician’s judgment as direct evidence of falsity.  The court ruled that these were both insufficient to prove falsity.  The circumstantial evidence would not allow a reasonable jury to find that the physician made false statements or harbored an intent to defraud.

The court also noted that the discrepancy in expert testimony, with respect to the appropriateness of the physician’s procedures, was consistent with intra-observer variability regarding the procedures.  The court pointed out that this variance of opinion undermined the certainty that is required for a criminal conviction, saying:  “expressions of opinion, scientific judgments, or statements as to a conclusion about which reasonable minds may differ cannot be false.”  Thus, to the extent that subjective medical opinions are incapable of confirmation or contradiction, they could not be used to establish proof of falsity.