What Exactly Constitutes Healthcare Fraud?

As we’ve discussed in the past, there are numerous different ways in which the criminal act of fraud can be perpetrated. One of the most common, and indeed one of the most financially impactful in terms of dollars stolen per year, is fraud committed within the context of the U.S. healthcare system. By most estimates, public programs like Medicare as well as private healthcare programs lose billions of dollars every year to healthcare fraud, and a vast majority of these schemes are carried out by healthcare providers.

Generally speaking, healthcare fraud can refer to any intentional deception used in the process of filing a healthcare claim in order to obtain some sort of benefit—usually financial in nature. There is a nearly limitless number of ways in which healthcare fraud can be committed, and anyone from providers to patients to insurers can be charged. The key point to note, however, is that the fraudulent act must be intentional. Mistakenly sending an incorrect bill to a patient with no intent to profit, for example, would not qualify.    

Most transgressions committed by healthcare practitioners have to do with providing false information to the insurance provider. Common examples include when they bill for care that was never provided, file duplicate claims for the same service, or alter medical records or claim information. Some fraudulent behaviors may also endanger patients, like when practitioners modify medical records or prescribe unnecessary treatment in order to claim a larger payment.

The average patient can also commit healthcare fraud in several ways. Forging or selling prescription drugs is one of the most blatant violations, but you are also prohibited from using false information to apply for programs or services. Additionally, you cannot borrow an insurance card or lend your own insurance card to someone else.

Patients can be complicit in healthcare fraud with practitioners when they receive payment in exchange for their medical/insurance information, unused drugs, or an agreement to exaggerate the extent of their medical issues. The practitioners can then make a profit when they are reimbursed for medically unnecessary services.

Healthcare fraud can be charged at both the state and federal levels under various statutes, and Florida even has a dedicated task force—known as the Medicaid Fraud Control Unit—intended to investigate and prosecute Medicaid fraud committed within the state.

Healthcare fraud is so common because it is perceived as a relatively low-risk crime with minimal harmful consequences for victims. However, aside from the damaging loss of the relevant licenses needed to practice medicine or provide insurance, those convicted of healthcare fraud could also face criminal penalties as high as 5 or even 10 years in jail per offense, as well as up to $250,000 or $500,000 (for organizations) per offense depending on the relevant statutes under which the crime is prosecuted. Those who profit from healthcare fraud and are later convicted are also normally ordered to pay back any benefits that were illegally obtained.       

Healthcare fraud charges can cause irreparable damage to your reputation—especially if you are a practitioner—and even result in substantial fines and incarceration. Always make sure you file insurance claims correctly and provide companies with the correct information. If you have any doubts about whether or not your actions could be perceived as fraud, or if you are currently facing healthcare fraud charges yourself, you should immediately contact a skilled defense attorney before speaking with investigators or taking any other action. The Law Office of Barry Wax can provide you with the effective, personalized legal counsel you need to defend against any type of healthcare fraud charge.

Written by Law Offices of Barry M. Wax

Law Offices of Barry M. Wax

For 34 years, I have provided both State- and Federal-Level representation for those facing charges ranging from wire fraud, mortgage fraud, and healthcare fraud to identity theft, drug trafficking, money laundering, murder, DUI, domestic violence and numerous other criminal charges. In every case, it is my commitment to one-on-one service and support that has separated the Law Offices of Barry M. Wax from other criminal defense firms. When it comes to your future, you need a strong defense and the ability to make the right choices and regain control of your life.