What Is Health Insurance Fraud?

While individuals can defraud government programs to receive health insurance benefits they are not entitled to receive, this article focuses on the type of health insurance or healthcare fraud that is more specifically, committed by healthcare providers.

The vast majority of health insurance fraud is committed by a minority of dishonest medical equipment manufacturers and “trusted” healthcare providers, costing tens of billions of dollars in financial losses each year in the United States, estimates the National Health Care Anti-Fraud Association (NHCAA).

Most common types of health insurance or healthcare fraud:

  • Billing private insurance companies, Medicare, or Medicaid for services never rendered through information from actual patients or identity theft.
  • Charging for tests or procedures that never took place or that were not medically necessary.
  • Billing for needless medical equipment.
  • Billing for a more expensive procedure than the one that was actually provided. This practice is commonly referred to as “upcoding.”
  • Performing a service that is medically unnecessary for the sole purpose of generating money from the insurance company.
  • Intentionally falsifying a patient’s diagnoses in order to justify medically unnecessary tests or procedures.

Health insurance fraud not only results in billions in financial losses every year, but it’s reflected in the high cost of health insurance, which is paid by patients and employers. Due to the seriousness of this white-collar crime, the Federal Bureau of Investigation (FBI) is tasked with investigating the worst offenders who engage in health insurance fraud.

“Health care fraud investigations are considered a high priority within the Complex Financial Crime Program, and each of the FBI’s 56 field offices has personnel assigned specifically to investigate health care fraud matters,” says the FBI’s website. “Our field offices proactively target fraud through coordinated initiatives, task forces and strike teams, and undercover operations.”

Related: Overview of White Collar Crimes

Contact my Miami criminal defense firm if you’re facing health insurance fraud charges. I practice state and federal defense and have over 30 years of experience.

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