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Types of Healthcare Fraud and Criminal Ramifications

Types of Healthcare Fraud and Criminal Ramifications

Healthcare fraud is a prevalent crime. Federal healthcare fraud involves fraudulent conduct with respect to any federal healthcare program or plan that provides health benefits to an individual. The plan or program is funded by the United States either directly or by way of a state healthcare fund.

Healthcare Fraud

Healthcare fraud involves either a healthcare provider or individual's attempt to defraud the federal government with respect to the receipt of healthcare payment or benefits. If one is charged with healthcare fraud the prosecution must show that:

  • The fraud was knowingly or willfully executed.
  • A scheme existed to defraud the federal government.
  • The intent of the scheme was either to gain payment for services or property through false representations.

If one is convicted of healthcare fraud, he or she may be fined up to $25,000, may be sentenced to up to ten years in prison, or both. If the defendant's conduct resulted in seriously bodily injury, the defendant may be sentenced to up to 20 years in prison.


Kickbacks of any sort are prohibited. The applicable federal statute provides that any individual, who knowingly or willfully receives or solicits cash or any other type of property as a kickback, may be guilty of healthcare fraud. The specific elements of the offense include:

  • Knowing and willful action on the part of the defendant.
  • Solicitation or receipt of payment for remuneration.
  • The kickback is done in exchange for services provided.

False Statements

If a healthcare provider or individual gives false statements with respect to the application of healthcare benefits or payments under any federal health care programs, healthcare fraud may have resulted.

Depending upon the facts of any given case, the prosecution must show that the provider or individual:

  • Made or caused to be made false statements in applying for federal healthcare benefits.
  • Concealed anything that may have affected an individual's initial or continued right to receive a benefit or payment.
  • The individual or provider had the intent to defraud the federal government.
  • If applicable, that the provider attempted to convert a benefit or payment to use other than for the use or benefit of the individual for which it was intended.
  • Presented a claim for a doctor's services when a licensed physician does not furnish the service.

If an individual is convicted of making false statements, he may be sentenced up to five years imprisonment; he may be fined up to $25,000, or both.

Theft or Embezzlement

If the healthcare provider or individual defendant embezzles or misapplies any assets of any healthcare program, the defendant may be charged with theft or embezzlement. If the offense involves an amount of less than $ 100, the defendant may be fined, sentenced to one-year imprisonment, or both. If the offense involved an amount exceeding $100 and the defendant is convicted, the defendant may be fined, sentenced to not more than ten years in prison, or both.

Miscellaneous Charges

The healthcare provider or individual defendant may also be charged with mail or wire fraud or obstruction of a criminal investigation in conjunction with the underlying healthcare fraud charge. For a conviction of either of the above-mentioned offenses, the defendant may be fined, sentenced to up to five years in prison, or both.

Copyright 2014 LexisNexis, a division of Reed Elsevier Inc.

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