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About Health Care Fraud

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All You Need to Know About Health Care Fraud

Health care fraud is a type of white-collar crime that occurs when you submit false or misleading information to your health care insurance company for the purposes of receiving benefits and/or reimbursements. If you commit health care fraud, you may face imprisonment or be fined heavily, regardless of whether you are a doctor or a patient.

There are many forms of health care fraud that could occur:

  • Individuals can obtain fully-covered prescription pills and sell them for a profit
  • Doctors and practitioners can overcharge or bill for unneeded procedures
  • File duplicate claims for services already rendered
  • Billing for non-covered services as covered services
  • Forging or selling prescription drugs

Who Might Commit Health Care Fraud?

Health care fraud can be committed by dishonest health care providers (doctors, dentists, lab technicians, or pharmacists) or by the health care plan holders themselves. Even a person who is not giving or receiving any benefits from the crime can commit health care fraud by allowing someone else to use his or her identity and insurance information in order to get medical treatment or health care services.

Examples of Fraud By a Health Care Provider:

  • Giving a false diagnosis to justify tests/procedures that are unnecessary;
  • Billing for medical procedures that were not really performed or that were not really needed;
  • Waiving member co-pays and over-billing the insurance provider instead;
  • Misrepresenting non-covered procedures (like cosmetic surgery) as covered ones

Example of Fraud By a Patient:

  • Altering health care bills or forging them to get health care reimbursements;
  • Filing claims for medical procedures and/or prescription medication that you did not receive;
  • Using someone else's insurance card or allowing someone else to use yours

Health Care Fraud vs. Mistake

It is important to distinguish between committing health care fraud and committing a unintentional mistake. A health care provider or practitioner who unintentionally makes a mistake, omission, or improper payment would not be guilty of health care fraud. In order to commit fraud, a person must knowingly and intentionally engage in a plan, activity, and scheme in providing misleading information with the intent to make a profit or financial gain.

For example, a doctor who makes a mistake and accidentally bills a patient for a procedure that he if she did not receive is not guilty of health care fraud. However, a doctor who knowingly and purposely provides treatment that the doctor knows that the patient does not need and bills the insurance company for the treatment in order to gain a financial profit is committing health care fraud.

What Are the Penalties for Health Care Fraud?

Federal law provides civil and criminal penalties for health care fraud. The penalties that one can face if convicted of health care fraud could include:

  • Lengthy jail or prison time
  • Fine of up to $250,000
  • Restitution for any amount that the defendant profited
  • Probation
  • Loss of professional license

Should I Consult an Attorney If I Am Accused of Health Care Fraud?

Health care fraud is not a minor crime, and a conviction of health care fraud could lead to significant jail time and the loss of a professional license to practice. If you are accused of health care fraud, you should contact a criminal defense attorney immediately. A criminal defense attorney can explain your rights and help defend you in court if needed.

Photo of page author Kourosh Akhbari

, LegalMatch Legal Writer

Last Modified: 11-11-2015 02:08 PM PST

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