A large part of our practice at Willey & Chamberlain involves allegations of health care fraud. In handling such matters we represent a variety of clients including physicians, dentists, therapists, social workers — as well as the entities which employ them. The confusing and complex area of health care law, however, may also ensnare patients and people other than health care professionals. Understanding health care fraud and what actions it actually includes remains important.
Health care fraud occurs when a person lies or acts deceptively when making health care claims. This white collar crime has significant criminal penalties, including prison sentences and restitution, and both state and federal laws address the issue. There can also be significant civil penalties, such as loss of license or loss of benefits.
Many dishonest acts fall under the definition of health care fraud, and both health care providers and patients may commit these crimes. Part of understanding health care fraud is knowing which possible acts may be classified as health care fraud.
Fraudulent schemes by health care practitioners may include:
- Obtaining prescriptions to sell on the black market
- Billing for services that were never provided
- Billing for a service not covered by an insurance policy
- Hiring unlicensed staff
- Prescribing unnecessary treatment
- Intentional incorrect reporting or modifying of medical records
Patients may also commit health care fraud, including:
- Submitting false information when applying for services
- Forging or selling prescription drugs
- Using benefits for purposes not related to receiving medical care
- Using someone else’s insurance card or loaning your own
Note that this only represents a small number of the specific crimes that constitute health care fraud, and many more actions may be considered fraudulent.