Health Care Fraud – 18 U.S.C. § 1347

Health care fraud under 18 U.S.C. § 1347 is a serious federal crime involving schemes to defraud health care benefit programs such as Medicare, Medicaid, or private insurance providers.

Federal authorities aggressively investigate and prosecute these offenses because fraudulent medical claims increase healthcare costs and undermine the integrity of public benefit programs.

Health care fraud typically occurs when a person or organization knowingly uses false statements, misrepresentations, or deceptive practices to obtain money or medical services from a health care program.

The central element prosecutors must prove is intent to defraud, meaning the defendant knowingly engaged in deceptive conduct to obtain benefits or payments they were not entitled to receive.

Investigations are commonly conducted by the Federal Bureau of Investigation (FBI), the U.S. Department of Justice (DOJ), and federal inspectors general responsible for oversight of government health programs.

If you are under investigation or charged with health care fraud, the consequences can include substantial fines, prison sentences, and professional penalties, making experienced legal representation essential.

For the best chance at a positive outcome, consider reaching out to an experienced California federal criminal defense attorney at Eisner Gorin LLP.

We're here to help—simply call (818) 781-1570 or contact us through our website to schedule a consultation.

What Is Health Care Fraud?

Under 18 U.S.C. § 1347, it is illegal to knowingly execute or attempt to execute a scheme to:

defraud a health care benefit program, or
obtain money, property, or services from a health care program through false or fraudulent representations.

The law applies to fraud involving both public health programs (such as Medicare and Medicaid) and private health insurance companies.

Examples of health care fraud include:

submitting false insurance claims
misrepresenting eligibility for medical benefits
billing for services that were never provided
falsifying patient records
prescribing unnecessary treatments for profit

Unlike some criminal statutes, the defendant need not know the specific law being violated—knowingly providing false information to obtain benefits is sufficient to satisfy the intent requirement.

What Is Insurance Fraud?

Health care fraud is closely related to insurance fraud, which involves submitting false claims to insurance providers to obtain payments.

Federal law generally requires insurance companies to pay legitimate claims within 30 days, which creates opportunities for fraudulent billing schemes before investigators can fully review each claim.

Because of this risk, federal law broadly prohibits schemes designed to obtain payment for services or benefits through deception or false statements.

A related statute, 18 U.S.C. § 1033, criminalizes certain fraudulent activities involving insurance companies.

Another related law, California Business and Professions Code 650, known as the anti-kickback law, bans healthcare providers from offering or accepting any rebate, refund, or "thing of value" as compensation for referring patients or clients.

The federal Anti-Kickback Statute (AKS) is a strong law that bans paying, offering, soliciting, or accepting anything of value in exchange for referrals related to federally funded healthcare programs like Medicare and Medicaid.

Health Care Fraud by Medical Providers

Healthcare providers are frequent targets of federal investigations when billing practices appear suspicious or inconsistent with medical standards.

Common types of fraud involving providers include:

Double Billing

Submitting multiple claims for the same medical service.

Upcoding

Billing for a more expensive procedure than the one actually performed.

Unbundling

Separating a single service into multiple billing codes to increase reimbursement.

Phantom Billing

Billing for medical services or patient visits that never occurred.

Billing for Unnecessary Services

Charging for tests or treatments that were not medically necessary.

Other conduct that may trigger investigations includes:

falsifying patient records
accepting illegal referral kickbacks
prescribing unnecessary medications
misrepresenting services to Medicare or Medicaid

Even small billing irregularities may trigger federal investigations if authorities suspect fraudulent intent.

Health Care Fraud by Patients or Individuals

Health care fraud is not limited to medical providers. Patients and other individuals can also face criminal charges.

Examples include:

Insurance Identity Theft

Using someone else's health insurance information or allowing others to use your policy.

Fake Insurance Schemes

Collecting personal information from individuals to bill fraudulent medical claims or enroll them in nonexistent insurance plans.

Impersonating Medical Professionals

Providing medical services or submitting insurance claims while pretending to be a licensed healthcare provider.

Prescription Drug Fraud

Fraud involving prescription medications is another common area of federal prosecution.

Examples include:

Doctor Shopping

Visiting multiple doctors to obtain duplicate prescriptions for controlled substances.

Prescription Forgery

Creating or altering prescriptions to obtain medications illegally.

Prescription Diversion

Selling or redistributing medications obtained through legitimate prescriptions.

Prescription fraud cases are often investigated because they contribute to broader public health issues such as the opioid crisis.

Health Care Fraud Conspiracy – 18 U.S.C. § 1349

In many cases, federal prosecutors also charge health care fraud conspiracy under 18 U.S.C. § 1349.

A conspiracy charge arises when two or more individuals agree to commit health care fraud and take steps toward carrying out the scheme.

For example, a conspiracy may involve:

recruiters who bring patients into fraudulent clinics
doctors who bill Medicare for services never provided
participants who receive kickbacks for using their insurance information

Even if the fraudulent plan is unsuccessful, individuals involved in the agreement may still face conspiracy charges.

Penalties for Health Care Fraud

Federal penalties for health care fraud can be severe.

A conviction under 18 U.S.C. § 1347 may result in:

up to 10 years in federal prison
substantial financial fines
restitution to victims or government programs

Enhanced penalties apply if the fraud causes harm:

up to 20 years in prison if serious bodily injury results
up to life in prison if the fraud results in death

A conviction for health care fraud conspiracy under 18 U.S.C. § 1349 can also carry up to 10 years in prison, along with fines and restitution.

Related Federal Health Care Fraud Charges

Health care fraud investigations often involve additional federal statutes.

Common related charges include:

Medicare or Medicaid Fraud

Fraud involving government healthcare programs.

False Claims Act Violations

Submitting fraudulent claims for payment to the federal government.

Anti-Kickback Statute Violations

Offering or receiving payments for patient referrals.

Stark Law Violations

Improper financial relationships between doctors and medical service providers.

Controlled Substances Act Violations

Illegal prescribing or distribution of controlled medications.

Because many healthcare fraud cases involve multiple statutes, defendants may face several charges at once, increasing potential penalties.

Defending Against Health Care Fraud Charges

Federal health care fraud cases often involve complex financial and medical records. Several defense strategies may be available depending on the evidence.

Lack of Intent

Prosecutors must prove the defendant intended to defraud the health care program. Honest billing errors or administrative mistakes may undermine this element.

Insufficient Evidence

The government must prove every element of the offense beyond a reasonable doubt.

Legitimate Medical Services

Defense attorneys may show that services billed were medically necessary and properly documented.

Improper Investigation

Evidence obtained through illegal searches or violations of constitutional rights may be suppressed under the Fourth Amendment.

Lack of Knowledge

Individuals accused of participating in a scheme may argue they were unaware of fraudulent activity.

Frequently Asked Questions

What qualifies as health care fraud?

Health care fraud involves knowingly submitting false claims or using deception to obtain money or services from a health care benefit program.

Who can be charged with health care fraud?

Doctors, pharmacists, clinic owners, patients, billing specialists, and others involved in fraudulent billing schemes may face charges.

What is the maximum sentence for health care fraud?

A conviction may result in up to 10 years in prison, with longer sentences if injury or death occurs.

Can honest billing mistakes lead to criminal charges?

Simple billing errors typically do not result in criminal liability unless prosecutors can prove intentional fraud.

Should I speak with investigators if contacted?

It is generally advisable to consult with a defense attorney before speaking with investigators.

Importance of Early Legal Representation

Federal health care fraud investigations often involve complex audits, financial analysis, and extensive document review. Prosecutors frequently rely on expert witnesses and forensic accounting.

An experienced federal criminal defense attorney can analyze the allegations, review billing records, and challenge the government's evidence.

If you are under investigation for health care fraud under 18 U.S.C. § 1347 or conspiracy under 18 U.S.C. § 1349, obtaining experienced legal counsel as early as possible may significantly impact the outcome of your case.

Eisner Gorin LLP is ready to support you. Feel free to schedule your consultation by calling us at (818) 781-1570 or simply using the contact form—we look forward to hearing from you!