Federal Healthcare Fraud

What Is Health Care Fraud?

The term health care fraud broadly covers any attempt to abuse or manipulate insurers, state or federal government health care programs for profit. The vast majority of this type of fraud is committed by health care providers, but patients can also defraud the system.

Examples of health care fraud by providers may include:

• Billing insurance companies or government programs for medical services not actually provided (often through falsified or stolen patient records)
• “Upcoding”—billing for a more expensive treatment or procedure than was actually performed
• Performing unnecessary medical services or procedures and billing for them (sometimes including falsely diagnosing a patient to justify the service)
• Billing separately for each step in a medical procedure to increase the total cost of the procedure (a practice known as “un-bundling”)
• Obtaining subsidized or covered prescription medications under false pretenses, then selling them for a higher price
• Accepting kickbacks for referrals from other members
• Practicing medicine without proper training or licensing, or fraudulently treating patients (also known as medical fraud or quackery)

Examples of health care fraud by patients may include:

• Faking a medical condition to obtain covered prescriptions, then selling the drugs
• Receiving health care services under someone else’s membership or insurance card (or allowing someone to use one’s card to do so)
• Forging prescriptions
• Obtaining health care coverage by providing false information

Individual states have their own laws regulating health care, but health care fraud at any level is a federal crime and can be tried at the federal level. For minor incidents, the government may opt to invoke only civil penalties (i.e., restitution for the value of what was unlawfully taken by fraud). More advanced cases of health care fraud are tried at the criminal level, punishable by fines of up to half a million dollars per count, and prison sentences of 5-10 years per offense. If bodily harm occurs because of the fraud, the sentence can be up to 20 years, and if death occurs, it can mean life in prison.

Defending Against Health Care Fraud Charges

As with most forms of fraud, the government must prove your intention to defraud, not just show that you attempted or completed the action. (Fraud must be committed purposely; mistakes are not illegal.) Our team of experienced federal criminal defense attorneys understands the nuances and complexity of the laws regulating health care as they pertain to your case. We’ll investigate the charges and the circumstances thoroughly, discuss your options and your rights, and employ effective defense strategies on your behalf beginning well before the case goes to trial, during the trial itself, and if necessary, after the trial.

Healthcare is a complex industry that is heavily regulated and investigated by federal agencies, including the FBI and the DEA. Because of this, healthcare providers often encounter a wide range of very serious allegations that can affect their careers, families and futures.