Medicolegal Sidebar: Expanding Hospital Liability—The Concept of Willful Blindness

Excerpt

Healthcare spending in the United States far exceeds that of other nations such as Australia, United Kingdom, France, and Germany [7]. In fact, US healthcare expenditures in 2015 increased 5.8% over the previous year, to reach USD 3.2 trillion, or close to USD 10,000 per person [1]. The federal government is concerned that healthcare fraud may contribute to higher healthcare costs. Accordingly, federal prosecutors have aggressively targeted physicians and other healthcare providers who are suspected of fraudulent billing practices, under a statute titled 18 U.S.C. § 1347 [4]. This statute addresses providers who attempt to defraud any healthcare benefit program through false billings or other misrepresentations that are designed to obtain money from the program. If convicted, a defendant charged under § 1347 can face fines and prison. The statute specifies that a guilty party need not have actual knowledge of the relevant law, nor even have a specific intent to commit a violation of such a law in order for the government to obtain a conviction. Since elective orthopaedic operations, such as knee arthroscopy, total joint arthroplasty, and spinal disc excision are high-volume operations that may be done in surgeon-owned facilities, the profession is particularly likely to attract scrutiny by government payers. …