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What is Health Care Fraud?

On Behalf of | Feb 9, 2014 | Uncategorized

The types of criminal fraud prosecuted by the state and federal government are virtually endless. From low-level cons to multi-million Ponzi schemes, the ways in which one person may dupe another are virtually limitless. Fraud is considered a white collar crime, and often, it is prosecuted by the state of Oklahoma. However, there are certain factors which make fraud a federal crime, and some types of fraud are always prosecuted at the federal level. One such type of fraud is Medicare fraud.

Medicare is a federal health care program, and because it uses federal funds to pay for medical care and equipment, fraudulently obtaining payment is considered to victimize the federal government. Any crime involving federal money is charged as a federal offense and prosecuted by the U.S. government.

But what is Medicare fraud?

Medicare fraud is a type of health care fraud that targets the Medicare system by using deceptive practices to receive payment to which one is not entitled. There are some types of health care fraud that are perpetrated by an individual patient: providing false information, loaning his or her insurance card or borrowing another person’s card, or selling prescriptions, for example. In general, though, health care fraud is carried out by physicians, medical equipment providers, and other medical professionals.

Common types of practitioner-committed health care fraud include the following:

  • obtaining unneeded, excess prescriptions and medical equipment and selling it for profit
  • billing for care never rendered or services never provided
  • filing duplicate claims for a single service or procedure
  • altering records, including dates, services, or member identity
  • billing for non-covered services
  • upcoding, or billing for more costly services and procedures than were given
  • reporting wrong diagnoses in order to bill for more costly services and procedures
  • accepting or giving referral kickbacks
  • waiving co-pays
  • ordering unnecessary procedures and treatment

Federal law prohibits and penalizes health care fraud in 18 U.S. Code § 1347. This statute defines health care fraud as follows:

  1. to defraud any health care benefit program; or  
  2. to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program

Under federal law, health care fraud is punishable by a maximum of 10 years in prison, unless the fraud resulted in seriously bodily injury. In that case, the crime carries a maximum sentence of 20 years in prison.


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