Health Insurance Fraud

Generally, health insurance fraud involves a scheme to defraud or deceive health insurers by using erroneous, deceptive or false information.

What is Considered Health Insurance Fraud?

Some common types of health insurance fraud schemes include the following:

• billing for medical services, procedures or supplies which were not provided
• billing for medical services at a higher cost than what was actually provided (known as “upcoding”)
• billing for medical services separately when the services were performed in a single service
• charging more than once for a medical service (known as “double billing”)
• performing excessive testing that was not necessary
• participating in kickbacks (where the medical provider receives a payment or benefit for making a referral)

Penalties for Health Insurance Fraud

There are both state based and federal based penalties for health insurance fraud.  Most states have insurance fraud statutes applicable to health insurance fraud.  These statutes usually define the crime as a felony, which carry significant fines which can be more than $15,000.00 and lengthy prison terms of more than ten years.  Additionally, there are many federal based laws applicable to health insurance fraud.  Mail and wire fraud statutes are frequently triggered.  Such laws carry tremendous penalties, with fines up to $1,000,000.00 and prison terms of up to thirty years.  Moreover, the Racketeer Influenced and Corrupt Organization Act (“RICO”) statute may apply.  Under RICO, fines, imprisonment of up to twenty years, forfeiture of proceeds gained from the activity, and other types of penalties may be imposed.  Finally, if the fraud involves Medicare, the False Claims Act and Anti-Kickback statutes may apply.

Getting Legal Help

There are substantial penalties if one is convicted of health insurance fraud.  Consequently, it is crucial to obtain the services of an experienced attorney.  This attorney will not only understand this complex area of law, but also the attorney will be able to easily navigate the system, preserve one’s rights and work to obtain the most favorable outcome.