Background and Facts

Health Care Solutions Network, Inc. (HCSN), operated mental health centers to provide psychiatric therapy in a partial hospitalization programa bridge between restrictive inpatient care and routine outpatient care. HCSN organized its business around procuring, retaining, and readmitting patients to maximize billing potential, without respect to their health needs. It ensured that patient files complied with strict Medicare requirements by editing intake information, fabricating treatment plans, and falsifying therapy and treatment notes. The scheme spanned seven years and amounted to more than $63 million in fraudulent claims.

At one of HCSN's facilities, Doris Crabtree was responsible for patient therapy notes. The notes were systematically altered and falsified to support Medicare claims. Convicted in a federal district court of conspiracy to commit health care fraud, Crabtree appealed to the U.S. Court of Appeals for the Eleventh Circuit. She argued that she had only been negligent and careless.

In the Words of the Court

WILSON, Circuit Judge:

* * * *

* * * According to Crabtree, * * * the evidence against [her] was primarily circumstantial and * * * did not show that [she] knowingly and voluntarily joined a conspiracy to defraud Medicare.

* * * *

* * * The very nature of conspiracy frequently requires that the existence of an agreement be proved by inferences from the conduct of the alleged participants or from circumstantial evidence of a scheme. The government need only prove that the defendant knew of the essential nature of the conspiracy, and we will affirm a conspiracy conviction when the circumstances surrounding a person's presence at the scene of conspiratorial activity are so obvious that knowledge of its character can fairly be attributed to [her]. The government can show that a defendant voluntarily joined a conspiracy through proof of surrounding circumstances such as acts committed by the defendant which furthered the purpose of the conspiracy. [Emphasis added.]

* * * *

The government put forth considerable evidence that Crabtree [was] directly aware of the essential nature of the conspiracy and that the circumstances at HCSN were so obvious that knowledge of the fraud's character can fairly be attributed to [her]. Multiple former-employees testified that Crabtree * * * complied with their requests to doctor patient notes so that they would pass Medicare review. * * * Numerous witnesses spoke of the overwhelming evidence that patients were unqualified for * * * treatment [at HCSN]: that it was obvious, and widely observed, that patients at HCSN suffered from Alzheimer's, dementia, autism, and forms of mental retardation that rendered treatment ineffective; that this was evidenced, for example, by patients * * * who were unable to engage in group therapy sessions; and that Crabtree [was] involved in multiple conversations about the unsuitability of [the] patients for * * * treatment [at HCSN]. One former-employee put it simply: "everybody was aware of the fraud."

Likewise, a reasonable jury could have found that Crabtree * * * voluntarily joined the conspiracy, given the substantial evidence of [her] role in furthering the fraud. The government put forth evidence that Crabtree * * * complied with requests to alter and fabricate notes for billing and Medicare auditing purposes; * * * and that [she] misrepresented the therapy that patients received when, for example, they * * * were * * * absent but notes indicated that they participated fully.

Answer the following questions with explanations in own words

Facts of the case

Who are the parties in this case?

What went wrong - why are they in court?

What question did the court have to decide in this case?

What facts did the court focus on in deciding the case?