It is hard to open a newspaper, turn on the TV or look online without seeing, hearing or reading about Health Care reform, Obamacare, or the Affordable Care Act. Over the last generation, while Health Care advances have helped prolong life, costs associated with those advances have made health insurance (and Health Care costs) skyrocket. Since the Federal government is the largest payer of Health Care services through Medicare and Medicaid, it has tried to control costs by every possible measure. This includes aggressive prosecutions of Health Care fraud. In 1996, Congress enacted the crime of Health Care Fraud under Title 18, United States Code, Section 1347. Essentially, the elements of Health Care Fraud mirror those of Mail and Wire Fraud. Anyone who knowingly and willfully executes a scheme to defraud any Health Care benefit program or to obtain by means of any false or fraudulent pretenses or promises any money of a Health Care benefit program in connection with the delivery of or payment for Health Care benefits is guilty of Health Care Fraud and can face up to 10, 20 or even more years in a Federal prison.

Before addressing and analyzing Health Care Fraud as set forth in Title 18, United States Code, Section 1347, it is worth noting that this offense is prosecuted with a firm hand.


In the context of the Federal government, nothing is truly “simple.” However, to understand as easily as possible the crime of Health Care Fraud pursuant to Title 18, United States Code, Section 1347, when you lie or cheat to get paid by Medicare, Medicaid or any other health insurance company, you are guilty of Health Care fraud.


One way to better grasp Health Care Fraud is to look at it as a scheme to defraud a health insurance company out of money involving Health Care services. While there is no direct correlation between the complexity of the scheme and the magnitude of the fraud (some frauds can be quite simple), the longer the duration of the criminal activity and the greater the size of the offense, the increased likelihood that other Federal crimes have been violated including Wire Fraud and Mail Fraud.

There are many different ways that the government can prosecute an individual for Health Care fraud – they can assert that the defendant did not provide the services claimed; that the services were not medically necessary; that the defendant charged more for services than was allowed (upcoding), that the services were based upon an illegal kickback arrangement and many more. Again, if the mail, telephones, internet or other services were used in this crime or caused to be used, your liability extends beyond the crime of Health Care Fraud. As you can see, Assistant U.S. attorneys and federal agents from the FBI or HHS-OIG have many avenues with which to seek criminal charges. It is for this reason that it is important that you confer with an experienced Federal Criminal Attorney, to seek informed and educated guidance, advice and advocacy.


There are two main elements of Health Care Fraud. First, that there was a scheme to defraud or obtain money from a Health Care benefit program in connection with the delivery of or payment for Health Care benefit items or services. Second, that the defendant, knowingly and willfully executed (or attempted to execute) the scheme.


Not a technical or legal definition, the easiest way to understand what constitutes a scheme to defraud is to take it outside of the Federal criminal context. If you concoct a plan, elaborate or not, to take another person’s or business’ property (it need not always be money but usually is) then a scheme exists.


Just like it does with Wire Fraud and Mail Fraud, the government does not shy away from enforcing Health Care Fraud. Arguably, it treats Health Care Fraud a little more serious in comparison to other Federal White Collar crimes. Health Care Fraud is punishable on a “sliding scale” in that you face up to 10 years in prison, a $250,000 fine and the payment of full restitution if you are convicted. However, if serious injury results from the violating Title 18, United States Code, Section 1347, a judge can sentence you to up to 20 years in prison. Even worse, if death results, Health Care Fraud is punishable by life in prison.

Like all other Federal crimes, Health Care Fraud is one of the offenses that can not only leave you incarcerated for years and decades, but can also ruin you financially. Call Spodek Law Group for a free legal consultation on your health care fraud case.