Criminal Healthcare Fraud

Abstract

Common fraud and abuse schemes include medically unnecessary procedures, up-coding, billing for services not rendered, and illegal inducements. In many instances it is unclear whether individuals or entities intentionally engaged in such conduct. As a result, most fraud and abuse enforcement actions are civil in nature and occur pursuant to the FCA or OIG administrative procedures. When fraudulent intent is present in these activities, however, the government may pursue criminal charges under a wide variety of statutes including the criminal healthcare fraud statute, 28 U.S.C. § 1347 (the “HCF Statute”). An individual or entity that “knowingly and willfully” engages in fraudulent activity against a healthcare benefit program, which includes private insurance companies, may be found criminally responsible under the HCF Statute and subject to a maximum sentence of 10 years.