Find the right lawyer now

Health Care Fraud Defenses

Find a Local Personal Injury Lawyer near You

What is Healthcare Fraud?

Healthcare fraud is a white collar crime which involves misrepresenting or concealing information or deceiving an individual or organization in order to receive benefits or make a profit.

Healthcare fraud can be committed by either individuals or healthcare providers and the laws regarding this type of fraud vary by jurisdiction. There are both state and federal laws which exist to prevent and punish this type of crime.

What is the Impact of Healthcare Fraud?

Whenever healthcare fraud is committed, the healthcare provider passes the costs to its customers. This type of fraud influences insurance rates by causing the premiums that individuals pay to rise to cover the losses of the insurance company.

When the fraud is committed by a healthcare provider, they can lose their professional license and in addition the healthcare of their patients may be affected. According to statistics, 10 cents of every dollar spent on healthcare goes towards paying for fraudulent claims.

Because of legislation enacted by Congress, healthcare insurance has to pay a legitimate claim within 30 days. The Federal Bureau of Investigation, the U.S. Postal Service and the Office of Inspector General are charged with the responsibility to investigate this type of fraud.

But because of the 30 day rule, these agencies typically do not have enough time to perform an adequate investigation before the insurer has to pay.

What are Some Examples of Healthcare Fraud?

There are many different types of healthcare fraud which can be committed by individuals, medical providers and insurance companies.

The primary motivation behind such fraud is to either get medical care without valid insurance or to profit financially. Fraud committed by individuals can include:

  • Providing false information to get medical coverage.
  • Visiting different doctors in order to get multiple prescriptions.
  • Using insurance that belongs to a different person.
  • Adding someone who is not eligible to an insurance policy by providing false information.
  • Exaggerating a particular claim.

Fraud committed by medical providers can include:

  • Falsifying a patient’s diagnosis to justify surgeries or procedures which are medically unnecessary or which are not covered.
  • Billing the patient for services and procedures which were not actually provided.
  • Billing for a different, more expensive service than the one which was actually rendered.
  • Engaging in duplicate submission of a claim for the same service when it was performed only once.
  • Billing each step of a particular procedure as if it was a separate procedure.

Fraud committed by insurance companies can include:

  • Denying payment on services, procedures, or prescriptions which are supposed to be covered.
  • Collecting premiums for policies on which the company does not intend to pay.

What are the Defenses to Healthcare Fraud?

There are certain defenses available to an individual or organization charged with healthcare fraud. One major defense is mistake. For an act to be considered fraud, it must be intentional, with the intent to defraud.

Sometimes, an act which appears fraudulent may actually be a mistake, without any intention to defraud. For example, an individual, healthcare provider or insurance company may accidentally omit information, bill improperly or make an error in payment.

Lack of evidence is also a major defense in many cases which involve allegations of fraud. There are also other defenses which may apply and this will depend on the facts of each individual case as well as state and local fraud laws.

How is Healthcare Fraud Investigated?

Insurance companies and law enforcement agencies often employ investigators to look into reports of suspected healthcare fraud. The fraud investigator reviews the evidence and also meets with the insurance company, medical providers and patients to collect information.

The investigators also sometimes use asset searches, surveillance, and other methods to conduct a thorough investigation into the suspected fraud. If the investigator determines that fraud has been committed, the evidence is then provided to the appropriate law enforcement agency or the local prosecutor to bring criminal charges against the perpetrator.

Should I Contact a Lawyer?

Healthcare fraud is a serious criminal offense and there are many different types of healthcare fraud. It would be beneficial to consult with a personal injury attorney if you need help understanding any healthcare fraud laws or if you have a claim against an individual or entity for healthcare fraud.

Your attorney can provide you with the latest information regarding the relevant laws which govern this issue, inform you of your rights and represent you in legal proceedings.

Photo of page author Arvind Ravikumar

, LegalMatch Legal Writer

Last Modified: 05-31-2018 12:06 AM PDT

Law Library Disclaimer
  • No fee to present your case
  • Choose from lawyers in your area
  • A 100% confidential service
What is LegalMatch?

We've helped more than 4 million clients find the right lawyer – for free. Present your case online in minutes. LegalMatch matches you to pre-screened lawyers in your city or county based on the specifics of your case. Within 24 hours experienced local lawyers review it and evaluate if you have a solid case. If so, attorneys respond with an offer to represent you that includes a full attorney profile with details on their fee structure, background, and ratings by other LegalMatch users so you can decide if they're the right lawyer for you.