The healthcare industry, akin to the financial industry, is a sector where public confidence is important.  The fact is that the overwhelming majority of healthcare and medical providers are honest, ethical, hard working people. On the other hand, there are also many medical providers who look to inflate the size of their bank accounts at the expense of their patients, insurance providers, and others. In actuality, National Health Care Anti-Fraud Association (NHCAA) reported that the financial losses from health care fraud activity can reach into the tens of billions of dollars every year.

Due to such huge financial losses, the FBI and other federal agents and prosecutors persistently investigate, pursue, and prosecute those who are involved in health care fraud schemes. When looking at the long-term and severe penalties associated with a conviction, alleged offenders need to get in touch with an experienced health care fraud attorney immediately. 

What is Health Care Fraud?

At its core, health care fraud is basically the providing of false or misleading information that is used to determine the amount of health care benefits payable. It is categorized as a white-collar crime and, due to the inherent nature of these fraudulent schemes, the perpetrator is able to gain financial wealth by shifting the costs down to customers and insurance providers. This genre of fraud is a widespread problem.  It can also be socially and financially ruinous. For this reason, and many others, the FBI, the U.S. Postal Service, and the Office of the Inspector General (OIG) are all charged with the task of investigating health care fraud.

An important characteristic of health care fraud, and part of the reason that federal agents aggressively prosecute it, is the effect of this fraud on insurance policy holders and consumers. Fraud inevitably leads to higher policy premiums, greater out-of-pocket expenses, and lower available benefits and coverage.

Common Ways Health Care Fraud Occurs

To get a better picture of what constitutes health care fraud, we can study some common examples. Primarily, theft of patient information is among the most prevalent types of health care fraud.  In this scenario, the medical providers use patient information to obtain reimbursement for services and goods they never provided. Several ways that criminals carry out this fraud include:

• Providing unlawful incentives, whether its cash or tangible gifts, to lure beneficiaries to to a specific clinic where patient identities are then obtained
• Harvesting patient information at free screenings (such as at health fairs) 
• Inducing medical staff to copy patient insurance information and share it with individuals involved in a scheme
• Buying patient information from other individuals involved in the scheme

Apart from the act of billing for products or services not provided, other methods that individuals use to commit health care fraud include:

• Billing for higher priced services or procedures than were actually furnished
• Actually giving medically unnecessary services for the purpose of procuirng insurance payments
• Faking a patient’s diagnosis to order unneeded tests, surgeries, or other services
• Billing individual steps of a procedure as if they were each a separate procedure
• Accepting kickbacks for patient referrals

Several types of health care fraud can be rather subtle as well. For example, there was a particular case where Alzheimer patients were situated in a room every day to watch the same movie over and over. On their invoices, they were being billed for group therapy for these sessions.

Potential Penalties for Health Care Fraud

People who are convicted of health care fraud could be facing extensive penalties, including big fines and years in prison. Pursuant to 18 U.S. Code § 1347, if you were discovered to be defrauding the health care system “in connection with the delivery of or payment for health care benefits, items, or services,” you could be looking at fines, imprisonment for up to 10 years, or both. Moreover, since this type of fraud is associated with health care, and as a result, a patient’s well-being, there are aggravated consequences as well, including:

• If the fraud caused some serious injury, the offender could be looking at up to 20 years in prison.
• If the fraud caused anyone’s death, the offender could be looking at life in prison.

In most matters of health care fraud, the prosecution has to demonstrate , beyond a reasonable doubt, two essential details. 

The prosecution must prove that 

1. the defendant knowingly and willfully carried out a scheme, the purpose of which is to defraud any health care benefit program and that 
2. the scheme was established to obtain any of the money or property associated with the health care benefit program. 

In plain English, the prosecution has the burden of proof.  By getting yourself an esteemed and hardworking criminal defense attorney, you can better come against these claims and clear your good name.