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The “Federal Healthcare Fraud Statute,” 18 U.S.C. 134,7, is a broadly defined statute under which medical providers can face severe penalties, including criminal prosecution for healthcare fraud charges. The federal healthcare fraud charges covered under U.S.C., Section 1347 include:
- Knowingly and willfully executing, or attempting to implement a scheme or artifice to defraud any healthcare benefit program,
- Obtaining, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by or under the custody of any health benefit program in connection with the delivery of or payment for healthcare benefits, items, or services.
Under Title 18 of the United States Criminal Code, it is a federal crime to defraud healthcare benefit programs or fraudulently obtain money from the healthcare benefit program. To prove their healthcare fraud case, the federal government investigators from the DEA and DOJ must show that the defendant intended to commit fraud through misrepresentation, false pretenses, or false promises.
Common Examples of Healthcare Fraud Under 18 U.S.C. 1347
- Upcoding services: billing the federal healthcare program for healthcare services that are more costly than the care services provided.
- Providing excessive services: when a health care provider bills Medicare for services greater than the patient required, given the circumstances and the patient’s health needs.
- Providing unnecessary services: filing Medicare claims for services that a patient did not need.
- Upcoding items: billing for items that are more costly than the items the patient received.
- Billing for services not rendered: billing Medicare for services not provided or that the patient did not need. This may involve billing for duplicate services through minor changes to bills and invoices.
Understanding the Legal Language of the Federal Healthcare Fraud Statute
“Attempts” and “Executes”
If healthcare fraud investigators cannot prove healthcare providers “executed” fraud, federal prosecutors can pursue “attempted” healthcare fraud charges. Under 18 U.S.C. 1347, attempts to commit healthcare fraud are punishable to the same extent as fraud. To prove an attempt, prosecutors must show the medical provider took substantial steps toward the commission of fraud.
“Willful and Knowingly”
In healthcare fraud cases, “knowingly” and “willfully” mean the accused must have known they were deliberately executing a fraudulent scheme. Prosecutors may present proof of the healthcare provider’s knowledge, for example, through communications with team members or patients. In some cases, the federal prosecutors have met the “knowingly” standard by showing the person was aware of the potential for illegal conduct and took tangible steps to avoid learning about the actions they, or their team, took.
“Healthcare Benefit Programs”
Healthcare benefit programs are defined as “any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual, and includes any individual or entity who is providing a medical benefit, item, or service for which payment may be made under the plan or contract.”
The federal authorities can charge medical providers for healthcare fraud and attempted fraud related to the following:
Medicaid
Medicare
Tricare
Private Health Insurance Plans
VA Health Benefits
Federal and State Benefit Programs
.
The Penalties for Healthcare Fraud Under 18 U.S.C. 1347
Violations of 18 U.S.C. 1347 are punishable by:
- Up to 10 years in prison and/or
- A large fine
18 U.S.C. 1347 also provides more severe punishment in cases where a violation of the Federal Health Fraud Statute causes serious bodily injury, potentially including up to 20 years in federal prison.
Conspiracy to commit federal healthcare fraud is punishable to the same level as healthcare fraud, with the maximum punishment of 10 years in prison or 20 years to life, depending on the severity of the resulting injuries.
In such cases, knowledge that the activities were fraudulent is not required to convict the healthcare provider.
Regulatory Consequences of Healthcare Fraud Cases
In addition to the criminal penalties imposed by federal law enforcement agencies, healthcare providers may face regulatory penalties when convicted of healthcare fraud. Healthcare providers may face medical review boards that can:
- Suspend the medical professional’s license
- Prevent the practitioner from working in the healthcare field
A healthcare fraud conviction will connect to the public record, potentially preventing professionals from renting office buildings, securing loans, and attending further education to build on their medical knowledge.
Frequently Asked Questions on 18 U.S.C. 1347
Does 18 U.S.C. § 1347 apply to individuals who are not healthcare providers?
Yes, the statute applies to anyone who knowingly and willfully defrauds a healthcare benefit program, not just healthcare providers or professionals.
Are there any safe harbors or exceptions under 18 U.S.C. § 1347?
The statute doesn’t contain explicit safe harbors, but prosecutors must prove all elements of the crime, including fraudulent intent. Legitimate disagreements about medical necessity or good-faith errors are generally not criminal.
What government agencies investigate potential violations of 18 U.S.C. § 1347?
Investigations are typically conducted by the FBI, HHS Office of Inspector General, and sometimes the DEA, often working together through Healthcare Fraud Strike Force teams.
Is a conviction under 18 U.S.C. § 1347 appealable?
Yes, like most federal criminal convictions, a conviction under this statute can be appealed to the appropriate U.S. Court of Appeals.
How does the government distinguish between healthcare fraud and legitimate medical disagreements?
The government typically looks for patterns of behavior inconsistent with professional standards, evidence of concealment, financial incentives for unnecessary services, and documentation that contradicts the care provided to distinguish fraud from legitimate disagreements about medical necessity or appropriate care.
Healthcare Fraud Defense Lawyers For Defense in 18 U.S.C. § 1347 Cases
The far-reaching consequences of a healthcare fraud conviction mean providers must take a proactive stance when facing healthcare audits and fraud investigations by the DEA, FBI, or DOJ. Contacting a proven healthcare fraud defense lawyer is the best first step in defending your healthcare practice, professional reputation, and personal freedom.
If you’re concerned about potential legal exposure in a healthcare fraud case or are currently the target of a federal investigation, now is the best time to book a free, confidential consultation with the healthcare fraud defense lawyers at Lowther | Walker. We are known for our work defending our clients in the largest healthcare fraud case the DOJ has ever prosecuted and for our years of success defending clients in complex healthcare fraud cases.
Our healthcare defense firm represents healthcare professionals across all 50 states, offering urgent healthcare fraud defense services in Florida, Georgia, Alabama, Kansas, and Oklahoma. Contact Lowther | Walker at 404-806-7997 or book your free confidential consultation online.