Can Medicare Fraud Lead to Prison?

A Medicare fraud conviction can result in imprisonment, but a billing error or improper payment does not automatically establish a crime. The charge, proof, and sentencing law matter.

What is the federal offense?

18 U.S.C. § 1347 prohibits knowingly and willfully executing or attempting a scheme to defraud a health care benefit program, or obtaining its money or property through false pretenses in connection with health care. The statute provides up to 10 years of imprisonment for the base offense, up to 20 years if the violation results in serious bodily injury, and any term of years or life if it results in death. These are statutory maxima, not an expected sentence per claim. Other statutes may have different elements and penalties.

Error, overpayment, or fraud?

A claim with missing documentation, coding error, or other improper payment may require correction or repayment without proving criminal intent. CMS states that its improper payment rate is not a fraud rate. The old article’s claim that about 10 percent of health care payments are fraudulent was unsupported. Deliberate false billing, fabricated services, and related communications raise different issues.

If audited or investigated, preserve claims and records, do not alter files, and seek legal advice about overpayment duties and potential civil or criminal exposure before responding. Roy J. Kahn, P.A. handles Miami white collar criminal matters. No outcome is guaranteed.

This is general information, not legal or billing advice.