Health care fraud can involve knowingly false claims or schemes to obtain payment from a health benefit program. A billing error or improper payment is not automatically criminal fraud.
Examples under investigation
Allegations can concern billing for services not performed, false diagnoses, medically unnecessary services, or knowingly inaccurate coding. “Unbundling” may be improper under a payer’s billing rules, but its criminal significance depends on knowledge, intent, and the charged law. A patient can also face allegations involving false claims or misuse of another person’s coverage.
Which laws apply?
Federal 18 U.S.C. § 1347 addresses a knowing and willful scheme to defraud a health care benefit program or obtain its money through false pretenses. The federal Anti-Kickback Statute governs certain knowing and willful remuneration connected to federal health program referrals. Florida’s patient brokering law has its own prohibitions, exceptions, and tiered penalties. The old claim that any referral kickback is usually a first degree felony with a $500,000 fine was inaccurate.
Administrative audits, civil claims, exclusion from programs, and criminal charges are different paths. CMS explains that improper payment estimates are not fraud rates. Preserve claims, medical records, contracts, and communications, and obtain legal advice before responding to investigators. Roy J. Kahn, P.A. handles Miami white collar criminal matters. No outcome is guaranteed.
This is general information, not legal or billing advice.
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