Health Care Fraud

Healthcare Fraud has been heavily prosecuted for many years. Recently, however, there has been increased political pressure to combat these violations because the impact to insurance companies and government programs is so substantial. This has resulted in an increase in the number of cases filed.

As a result of this new effort against Healthcare Fraud, many legitimate providers are experiencing a chilling effect and are reluctant to practice medicine and to bill as they once did.

What Constitutes the Crime?

In order to be convicted of healthcare fraud, the prosecution must prove all of the following elements:

  • You submitted false or fraudulent claims to the insurance company
  • You knew the claims were false or fraudulent
  • You intended to defraud the medical insurance company

The most common types of Healthcare Fraud is billing for services not rendered, or billing for services rendered but that were not medically necessary. In both instances the provider’s intent is at issue and must be determined. This is done by examining various factors such as the necessity of the procedures billed, whether the patient’s file has complete records, patient’s medical history, the relationship between the provider and other individuals associated with the practice and many other such factors.

What can lead to health care fraud charges?

  • Submitting claims for services that weren’t rendered
  • Submitting false claims
  • Submitting multiple claims
  • Prescribing unnecessary medicines
  • Ordering unnecessary patient tests
  • Upcoding


Although health care fraud can be filed as a misdemeanor if the loss is less than $950.00, the vast majority of these cases are felonies.

If the prosecution chooses to charge you with a felony, you face:

  • A maximum fine of $50,000, or restitution worth double the defrauded amount
  • A prison sentence of two, three, or five years in a county jail
  • A jail sentence of up to one year and fines

Legal Defenses to Healthcare Fraud Charges

Lack of Intent Defense- Submitting a false claim, by itself, is insignificant without establishing an intent to defraud. If the provider had a good faith belief that the procedure was medically necessary, or if there was a glitch in the computer system, for example, it would negate criminal intent.

Mistake of Fact Defense- This defense applies when a false or duplicate claim was mistakenly submitted. Billing the insurance company for the wrong service could have been an honest mistake.