18 U.S.C. Sec. 1347 HEALTH CARE FRAUD — ELEMENTS is a federal criminal statute that makes it a crime to defraud any health care benefit program. It is illegal to knowingly and willfully execute, or attempt to execute, a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations or promises, any of the money or property owned by, or under the control of, any health care benefit program. This statute has two main elements: fraud and health care benefit program. The fraud element requires that the defendant knowingly and willfully execute or attempt to execute a scheme to defraud or obtain money or property by false or fraudulent pretenses, representations or promises. The health care benefit program element requires that the fraud be perpetrated against a health care benefit program. This includes any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual, and any claim for such medical benefit, item, or service is paid for, in whole or in part, by a public or private entity. The types of 18 U.S.C. Sec. 1347 HEALTH CARE FRAUD — ELEMENTS are the fraud element and the health care benefit program element.
18 U.S.C. Sec. 1347 HEALTH CARE FRAUD - ELEMENTS
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Other forms of fraud and abuse in health care. Billing for services not rendered medically necessary. Double-billing for services rendered. Billing for covered service when the service provided was not covered.
In California, healthcare fraud is considered a ?wobbler? crime, which means it can be charged as a misdemeanor or a felony. Typically, the prosecutor decides based on the amount of money involved.
Examples of Health Insurance Fraud Falsifying a patient's diagnosis to justify the need for tests, surgeries, or other procedures that are not medically necessary. Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery.
Whoever, having devised or intending to devise any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises, or to sell, dispose of, loan, exchange, alter, give away, distribute, supply, or furnish or procure for unlawful use any
Common Types of Health Care Fraud Double billing: Submitting multiple claims for the same service. Phantom billing: Billing for a service visit or supplies the patient never received. Unbundling: Submitting multiple bills for the same service.
The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL).
Members can commit health care fraud by providing false information when applying for programs or services, forging or selling prescription drugs, using transportation benefits for non-medical related purposes, and loaning or using another's insurance card.
Examples: A physician knowingly submits claims to Medicare for medical services not provided or for a higher level of medical services than actually provided.