What is healthcare fraud?

December 28, 2020
What is healthcare fraud?

If you, a group of people or a company knowingly misstates or misrepresents something about the nature, scope or type of a medical service provided, healthcare fraud occurs. This often results in the insurer or company making unauthorized payments to receive a financial kickback.

According to the U.S. Department of Justice, healthcare fraud can occur with any type of insurer or health insurance company, including Medicaid, Medicare, private insurers and workers’ compensation providers. Healthcare fraud can also impact hospital care, home healthcare, skilled nursing care, physician services, x-rays, outpatient services and any other type of medical service rendered.

Examples of healthcare fraud

Some examples of healthcare fraud include:

  • Billing services separately when you should bill them with a single-service fee
  • Justifying medical payments by falsifying treatment plans or medical records
  • Maximizing payments by misrepresenting procedures or diagnoses
  • Billing for services that a doctor or other medical professional did not provide

Healthcare fraud can also include misrepresenting charges in accounting reports and soliciting kickbacks in exchange for different goods or services provided.

Potential defenses

You have to establish “fraudulent intent” for a healthcare fraud case to move forward in court. Depending on your case, you could argue that you did not act in bad faith or that you made an innocent error when creating medical documents or providing services.

For instance, if you face charges for over-billing an insurance company, you could argue that someone else in your office made a clerical mistake. Or you could state that the billing was appropriate in your professional opinion.


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