By: Onisuru Ojegba, Legal Intern to Firm
J.D. Candidate, Class of 2025
The George Washington University Law School
Health care fraud consists of an individual, a group of people, or a company knowingly misrepresenting the type, scope, or nature of the medical treatment or service provided, for the purpose of making illicit profits or benefits. These crimes can be committed by medical providers and patients alike, with both parties using different methods for their respective roles. Common fraud committed by medical professionals can include:
* Double billing, in which multiple claims for the same service are submitted to an insurance company
* Phantom billing, where a medical provider bills for a service visit or supplies the patient never received,
* Unbundling, which involves Submitting multiple bills for the same service, and Upcoding, where a patient is Billed for a more expensive service than what they actually received.
Common fraud committed by patients or other individuals can include
* false marketing to convince people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan
* Identity theft/identity swapping by using another person’s health insurance or allowing another person to use your insurance
* Impersonating a health care professional through providing or billing for health services or equipment without a license
Health care fraud is governed by Title 18 of the United States Code, Section 1347, which makes it a federal crime to defraud any health care benefit program or obtain, by fraudulent means, any money or property from a health care benefit program. (18 U.S.C. § 1347). The FBI is the primary agency responsible for investigating healthcare fraud, for both federal and private insurance programs. The FBI investigates these crimes in partnership with: Federal, state, and local agencies, Healthcare Fraud Prevention Partnership, and insurance groups such as the National Health Care Anti-Fraud Association and the National Insurance Crime Bureau.
The consequences of a health care fraud conviction are severe and carry many penalties along with the possibility of a lengthy prison sentence. For medical professionals convicted of health care fraud, there is a high likelihood of losing a medical license or being blackballed by the industry. Under the federal exclusion statute, individuals may be excluded from participating in any federal healthcare program if they were convicted of a criminal offense related to the delivery of an item or service under Medicare or a state health care program. These exclusions may also be mandatory, as the Office of the Inspector General (OIG) has no discretion in imposing the mandatory exclusions if the elements are satisfied.
Navigating the federal criminal system is a task that should not be endured alone. If you have a health care fraud matter that you would like to discuss with experienced federal criminal defense lawyers, please contact our team today for more information about what we can do to help.