Ron K. Elfenbein v. United States

Under 18 U.S.C. § 1347, a person is guilty of health care fraud if he willfully executes, or attempts to execute, a scheme to obtain money or property from a health care benefit program “by means of false or fraudulent pretenses, representations, or promises . . . .” In a so-called “upcoding” case like this one, the allegedly false representations are the numeric codes attached to a healthcare provider’s claim for insurance reimbursement. The selection of these codes, which represent medical services and procedures, are governed by a complex set of rules promulgated by the American Medical Association (“AMA”). The question presented—which has divided six circuits—is: When an allegedly false statement is premised on an ambiguous rule open to multiple reasonable interpretations, can the government secure a defendant’s conviction merely by persuading a jury that its preferred interpretation is “better”? (i)