Our insurance fraud division has successfully handled charges and accusations of insurance fraud brought by the FBI, National Insurance Crime Bureau, and the U.S. Attorneys’ Offices.

Our lawyer’s focus on white-collar crimes like fraud and conspiracy and can help you defend against charges related to:

Federal Insurance Fraud

The False Claims Act, 31 U.S. Code §3729, is the most common charge related to insurance fraud cases.  Violations of the False Claims Act are generally associated with:

  • Fabricating or exaggerating a claim;
  • Knowingly submitting false information on an application; and
  • Deliberately omitting relevant information on an application;

Health care providers and insurance companies can also face liability for:

  • Billing for services not rendered;
  • Waiving deductibles and copays;
  • Submitting false or altered data code sets; or
  • Evading state insurance regulations.

In order to be convicted of insurance fraud, prosecutors must prove that you:

  • Intentionally made a false or misleading statement;
  • The statement was made in connection with a claim or payment; and
  • The statement is material (in other words the statement can impact the ultimate outcome of a claim.

“Hard” v. “Soft” Insurance Fraud

There are many types of insurance fraud, but generally, insurance fraud is identified by two main categories:

  • “Hard fraud.” Hard fraud occurs when a person has purposeful intent and commits one of the many actions outlined above, with the purpose of gaining false compensation from insurance companies. Typically, hard fraud is carried out by individuals, but can also involve multiple parties or groups.  One example involves a case whereby the owner of a restaurant paid two teenagers to burn down her business in order to collect on the insurance policy.
  • “Soft fraud.” Soft fraud (also called “opportunistic fraud”) on the other hand, involves unplanned activities and are the most commonly seen. This is a type of fraud in which the perpetrator tells lies, or exaggerates the extent of damage in order to receive greater compensation from the insurer. For example, lying about the number of items destroyed in a flood, or exaggerating the value of your grandma’s favorite necklace lost in a house fire.

Billing Fraud

If you are a health care provider who is being investigated or charged with insurance fraud related to an issue with your billing, you must contact a federal criminal insurance fraud attorney immediately.

This can include charges associated with:

  • Billing for services not rendered;
  • Billing for services not medically reasonable or necessary;
  • Billing for higher levels of services than were actually provided; or
  • Billing for higher levels of services than were required by patients’ conditions.

These types of Healthcare fraud, Medicare fraud, and Medicaid fraud charges can carry heavy fines and long terms of imprisonment.

Exaggerating a Claim

Even the exaggeration of a claim can lead to charges of insurance fraud.

With such high lease payments and high loan payments, it may seem reasonable to exaggerate an insurance claim.

However, doing so may result in a government investigation into your claim.

Government Investigations of Insurance Fraud

Federal agencies have jurisdiction over insurance fraud that affects interstate commerce.

According to 31 U.S. Code §3733, Civil Investigative Demands, when the attorney general has reason to believe a person may have documents or important information related to a false insurance claim a subpoena may be served:

  • To produce documents material for inspection and copying;
  • To answer in writing questions that have to do with the documents;
  • To give oral testimony concerning the documents or important information;
  • To furnish any combination of the material, answers, or testimony.

Federal agencies will look into:

  • Bank accounts;
  • Patient records;
  • Tests/treatments were conducted;
  • Doctors who authorized tests/treatments; and
  • All the claims that have been submitted.

Criminal Charges

Depending on the specific facts of your case and circumstances surrounding insurance fraud, you can face very serious consequences, including:

  • False Claims Act Violations (31 U.S. Code §3729.) Violations of the False Claims Act may result in fines of up to $250,000, 5 years imprisonment, or both, for each false claim made.
  • Federal Health Care Fraud Violations (18 U.S.C. § 1347.)  Violations of the federal Health Care Fraud Statute may result in fines of up to $250,000, or imprisonment for up to 10 years.

Civil Consequences

In addition to facing fines and potentially prison in your criminal case, federal crimes like insurance fraud could mean facing civil charges for damages, restitution, and civil forfeiture of all property or assets connected to the fraud.

This means facing injunctions, restraining orders, and additional monetary penalties.

What are “Injunctions” and “Restraining Orders?”

18 U.S.C. § 1345 allows the Attorney General (“AG”) of the United States to commence a civil action in any federal court—known as an injunction—to prevent you from carrying any alleged insurance fraud.

If the court believes that you may have engaged in insurance fraud, the court will issue a temporary restraining order (“TRO”) to freeze your bank accounts and seize any assets that you may have obtained as a result of the fraud.

The AG’s objective in seeking a TRO is to prevent you from “withdrawing, transferring, removing, dissipating or disposing” of any money or property obtained as a result of the alleged insurance fraud.

The restraining order may allow the AG to “take any action warranted to prevent a continuing and substantial injury” to the victims of the fraud.

Establishing a Defense to Insurance Fraud

In cases of insurance fraud, one of the essential elements that the prosecution must prove is that you knew you were making false or misleading representations, or that you intended to commit insurance fraud for the purpose of unlawfully obtaining money from an insurance provider.

If the prosecution is unable to prove the element of knowledge or intent to commit the underlying fraud, it will be difficult to convict you of insurance fraud.

In some states, you may reduce the amount of damages alleged against you if you are able to show by a preponderance of the evidence (in other words show that it is more likely than not) that a payment under an insurance policy resulted from a valid loss, injury, expense, or service covered by the insurance policy as monetary damages.

Call an Insurance Fraud Attorney You Can Trust

Our Criminal Law Group has represented industry and corporate clients, doctors, pharmacists, administrators, clinics, hospitals, and other health care industry professionals against charges and allegations of insurance fraud.

We have the knowledge and background to successfully defend anyone prosecuted for healthcare and insurance fraud in both state and federal criminal proceedings.

We invite you to contact us now for a free consultation