Health Care Fraud

Healthcare Fraud is one of the most heavily prosecuted federal offenses. Because it involves government-funded programs like Medicare, Medicaid, and TRICARE, the Department of Justice (DOJ), Department of Health and Human Services Office of Inspector General (HHS-OIG), and FBI devote enormous resources to these cases.

What Is Healthcare Fraud?

Healthcare fraud generally involves knowingly executing or attempting to execute a scheme to defraud a healthcare benefit program or to obtain money or property under false or fraudulent pretenses.

Key statutes include:

  • 18 U.S.C. 1347—Healthcare fraud (specific to healthcare benefit programs)

  • 18 U.S.C. 1341/1343—Mail and wire fraud, often added as companion charges

  • 18 U.S.C. 1035—False statements relating to healthcare matters

  • 18 U.S.C. 371—Agreements to defraud healthcare programs

Common Healthcare Fraud Scenarios

  • Biling fraud. Upcoding (billing for more expensive services), phantom billing (billing for services not provided), or unbundling (splitting services to increase reimbursement)

  • Kickbacks: Paying or receiving improper payments for referrals, patients, or prescribing decisions

  • Medically Unnecessary Services: Ordering tests, procedures, or prescriptions that are not medically justified.

  • Prescription Fraud: Distributing controlled substances outside the usual course of professional practice.

  • Duration Medical Equipment Fraud: Billing for devices not delivered, or delivering lower-quality equipment than billed.

  • Home Health Fraud: Inflating hours, billing for non-eligible patients, or falsifying documentation.

Healthcare fraud prosecutions are among the most complex and high-stakes federal cases. They combine criminal exposure, financial penalties, and devastating professional consequences. But the government must still prove willfulness, intent, and materiality beyond a reasonable doubt. When the stakes are high, having experienced federal criminal defense counsel is critical.