Health care fraud is when someone knowingly defrauds an insurance company or government insurance agency.

The federal government has specific laws related to health care fraud that are explicitly designed to help protect the government and insurance agencies from being overcharged and defrauded.

Medical professionals need to be especially careful with there practices to make sure they are not engaging in health care fraud.

Continue reading to learn about the civil and criminal statutes that govern charges of health care fraud.

A Note For Health Care Providers

If you are a health care provider, you have to be careful of your actions in billing insurance companies and government insurances because you may face criminal liability if you are filing false reports.

For example, you may have committed health care fraud if you are making reports to Medicare for a patients doctor visits if the patient did not actually see the doctor.

Call A Health Care Fraud Attorney Today

If you or your business are under investigation for health care fraud, it is imperative to speak to an attorney with experience in handling these types of cases.

A successful charge of health care fraud can lead to serious fines and possibly of imprisonment.

If you are confronted with an investigation or charges of health care fraud you should speak to an experienced health care fraud attorney.

The attorneys at the Criminal Law Group can provide you with the defense you need to fight charges related to health care fraud and insurance fraud.

Call us today for a free legal consultation.

Federal Health Care Fraud Statute

The most prominent of the laws is the criminal health care fraud law 18 U.S. Code § 1347. This law makes it illegal to knowingly defraud a private insurance company or a government insurance program.

A violation of the criminal health care fraud law could result in:

  • Jail time up to 10 years; and
  • Criminal fines up to $250,000.

If your violation of health care fraud results in serious injury, you may face up to 20 years, and if someone dies as a result of your health care fraud, you may end up serving a life sentence.

The Element of “Intent.”

Under the criminal health care fraud statute you need to intentionally be acting in a way to defraud, which means any prosecutor would need to prove your intent.

Without intent, you may not be held liable under this law.

Additionally, the False Claims Act provides criminal and civil liability for making false records or claims to the government.

The violation of the False Claims Act may either be knowingly or with a complete disregard for what is going on. This means that if you are blatantly ignorant, you may be held liable under this law.


The civil penalty under the False Claims Act is:

  • $11,000 for each false claim; and
  • Up to three times the damages to the government for the claim.

The criminal liability under this law can be assessed only if someone knowingly makes a false claim, and the criminal punishment is a fine up to $250,000 and up to 5 years imprisonment.

Government Agencies

The Department of Justice (DOJ) has a unit dedicated to finding instances of health care fraud.

The Health Care Fraud Unit is organized under the Criminal Division of the DOJ, and they are in charge of investigating instances of health care fraud cases throughout the United States.

This Unit also operates a total of 9 strike force locations which help with the prosecution of health care fraud.

Initiating Investigations

There are several ways that government is tipped off about possible cases of healthcare fraud.

A patient might report an incident of health care fraud when they and their insurance company are charged for services not rendered or overcharged.

Because of deductibles on insurance plans, several patients will try and argue their bills which could tip off an investigation if there is a pattern of problems with billing.

The FBI is also one of the primary investigators of an instance of health care fraud.

The FBI might use undercover agents or confidential informants to get information from medical practices to gather evidence.

They may also audit your practice and demand production of your patients’ medical records in order to compare what is being performed to what is being billed for or claimed through insurance.

What to Expect in the Legal Process

An experienced attorney will help you throughout a government investigation by assessing the evidence and creating a strategy to deal with the investigators.

Just because you are under investigation, it does not mean that you have done anything wrong or that you will get charged but having an attorney from the onset of an investigation may increase your odds of defeating any healthcare fraud allegations.

Following an investigation, the Attorney General’s Office will determine if they want to press charges against you for health care fraud.

They will then present the evidence to a grand jury to determine if there is enough evidence to indict. It is best practice to speak to an attorney before the grand jury in hopes of getting charges dropped during the grand jury hearing.

Taking a Plea Deal.

If you are charged at any point, you may be offered a plea deal by the prosecutor. However, it is advised that you speak to an attorney and truly go over and understand the deal.

A plea to the crime of health care fraud can also lead to certain civil penalties as well.

During the investigation process or after an arrest they may begin questioning you to try and elicit incriminating information. Be sure to have an attorney present to avoid incriminating yourself.

What Happens If I am Indicted?

If you are indicted, the prosecution will prepare for trial by gathering evidence and securing witnesses. Your attorney should review all of the evidence and begin to prepare the best defense for a trial.

A successful conviction of health care fraud could come with criminal fines and jail time and significant civil penalties.

One of the largest costs related to criminal health care fraud charges comes in the form the civil monetary penalties.

If you are charged criminally and civilly, you may be liable for damages and restitution.

Do Not Let This Happen To You

A case of health care fraud could result from a simple mistake or a mistake from your employee.

These minor mistakes are flagged by the government as potential health care fraud, so understanding what happened and what the authorities are searching for is important in any case of health care fraud.

Having an attorney present could help you sort out discrepancies with the police.  Your Criminal Law Group attorney can work with the authorities to help remedy or explain any potential problems in your case.

Common Tactics Used By Prosecutors

Another common tactic from prosecutors in health care fraud cases is to charge the individual with a multitude of different statutes under fraud statutes. If the crimes are overlapping or if there are unfound crimes listed it is important for an attorney to work to have these excess charges dropped.

If you are part of a medical group, it is important to understand what the implications are against you as opposed to the group as a whole.

For conviction of health care fraud, the prosecutor will need to show that you specifically were the one that committed the offense (s).

If you were not the one who committed the offense, a possible defense would be that you did take part in the furthering of the criminal offense.

In recent years, the federal government has continuously prosecuted individuals for committing health care fraud.

The FBI estimated that health care fraud costs close to $80 billion a year for the federal government. Several schemes fall under health care fraud such as; Kickbacks, bribes, billing errors, code problems, self-referrals, fraudulent claims, billing without services, or falsifying records.

What is a Kickback Scheme?

St. Judes in 2011 was ordered to pay $16 million for their operation of a kickback scheme. This case is important because the way it came to the authorities attention was through a whistleblower.

What is a “Whistleblower?”

The whistleblower, in this case, came forward and brought an action against St. Judes for their operation of this scheme, which then lead to civil penalties. If there is a whistleblower who is in cooperation with authorities, it could lead to much more than just civil penalties.

A successful conviction may land you in jail for quite some time; (like Atif Barbar Malik, who was sentenced to 8 a year sentence for 26 counts of Kickbacks and fraudulent billing.)

Mr. Malik admitted to defrauding the government of over $2 million.

In addition to the eight years, he will also have to pay a fine and restitution of close to $500,000.  


Knowledge is an essential factor in a case for health care fraud but there is a chance knowledge may be inferred to you if should have known something that was obvious to you.

The idea here is you can not bury your head in the sand as a way to get out of liability for health care fraud.  (In United States v. Sanjar the court held that a jury might infer knowledge when a person closes their eyes to something that should have been obvious to them.  United States v. Sanjar, 876 F.3d 725, 744 (5th Cir. 2017.))

Maintaining Compliance

The best way to avoid liability for health care fraud is to keep accurate and detailed records of all insurance based claims.

This applies to all levels of the medical profession from admin to the doctors.

It is important to train all employees the proper method of entering in all charges to insurance companies to try and avoid any false billing.

Contact a Criminal Health Care Fraud Attorney Today

If you are under investigation or charged with health care fraud, you should speak to an attorney right away.

Being proactive with your attorney could help you avoid charges or lessen the severity of any charges.

Communication with the authorities is tricky regarding complex health care fraud, so if you are unrepresented, you might end up accidentally incriminating yourself.

An attorney can help you plan the next step.  Having an attorney present during questioning can help you maintain your innocence throughout the investigation process.

Health care fraud can be a very serious charge and having a criminal attorney that specializes in federal criminal health care law can make all the difference.

Call us not for a free consultation.