Federal Healthcare Fraud: 18 U.S.C. § 1347

What is Healthcare Fraud?

18 U.S.C. § 1347 makes it a federal crime to defraud any healthcare benefit program or obtain, by fraudulent means, any money from a healthcare benefit program. This includes federal programs like Medicare as well as state-federal programs like Medicaid run by the Virginia Department of Medical Assistance Services or the DC Department of Healthcare Finance.

The statute defines healthcare fraud as when an individual knowing and willfully executes or attempts to execute a scheme defrauding any healthcare benefit program by false pretenses or representations, or promises to obtain money or property controlled by any health care benefit program.

This means that, in order to sustain a conviction of healthcare fraud under 18 U.S.C. § 1347, the government must prove beyond a reasonable doubt:

• • A scheme or plan to defraud a health care benefit program, or money obtained by false pretenses
  • An intent to defraud by the defendant

Common Types of Healthcare Fraud

Healthcare fraud can involve patients/beneficiaries and providers. Examples of fraud can range from filling out paperwork to billing for services not provided. For example, on the patient/beneficiary side, a person may be prosecuted for fraudulently claiming that they are eligible for Medicaid benefits when they know they are ineligible. On the provider side, a doctor or nurse may bill for services not rendered or for services a patient did not need.

Some common types of healthcare fraud include:

• • Double billing: when providers submit multiple claims for the same service
  • Billing for services not provided/needed: when providers submit claims for services they either did not provide or the patient did not need
  • Unbundling: when providers submit multiple bills for the same service
  • Upcoding: when providers bull for a more expensive service than the patient actually received
  • False statements on enrollment forms: when patients defraud Medicare or Medicaid by providing false information on forms regarding eligibility
  • Identity swapping: when a patient uses another person’s health insurance or allows someone else to use their health insurance

Some common defendants for healthcare fraud cases include:

• • Doctors
  • Nurses
  • Pharmacists
  • Patients
  • Billing servicers
  • Beneficiaries
  • Healthcare workers

Potential Defenses to Healthcare Fraud

Some common defenses to healthcare fraud include:

• • No intent to defraud: demonstrating that potential errors were unintentional could show that there was no intent to defraud a healthcare benefit program
  • Mistake: again, if there was an honest mistake, the government may not be able to prove an intent to defraud
  • Insufficient evidence: after assessing the evidence, the government may not have enough evidence to prove its case beyond a reasonable doubt

Potential Penalties for Healthcare Fraud under 18 U.S.C. § 1347

A violation of 18 U.S.C. § 1347 is punishable by up to 10 years in federal prison and/or a fine. However, a healthcare fraud violation that results in serious bodily injury to any individual is punishable by up to 20 years in federal prison. Moreover, a healthcare fraud violation that results in death to any individual is punishable by up to life in federal prison. A court may also order restitution and fines.

There are also a number of collateral consequences of a healthcare fraud conviction, including the loss of a medical, nursing, or professional license, the inability to find work in healthcare again, impacts on your reputation, security clearances, and a permanent criminal record.

How Our Federal Criminal Defense Attorneys Can Help You

Federal healthcare fraud cases are complex and the defenses available depend on the specific facts of each case. Due to the severity of penalties and the intricacies of healthcare fraud crimes, it’s crucial for those facing federal healthcare fraud charges to work with experienced federal criminal defense attorneys. We assist clients in the US District Court for the District of Columbia and the US District Court for the Eastern District of Virginia. Contact us today for a free, confidential consultation regarding your federal healthcare fraud charges.