prescriptions spilled out of a bottle

It was a normal Tuesday for a working Mom as she took her son to the doctor’s office to get a check-up during her lunch break. As the child was getting checked over by the doctor, the nurse running the front desk was taking careful notes about which services were being used. A moment of distraction from a patient in the waiting room, caused her to hit the wrong key on her computer. It added another charge to the bill, and it was never caught.

The mom and child went home and went about their business as usual. A month has passed and the bill from the doctor’s visit finally comes in. The mother is surprised to find that the bill is a lot higher than she expected, and upon further investigation, finds a charge for a service they never got. Due to the high wait times for the doctor’s office customer service across several weeks, the mother gets fed up. With the bill going to collections due to no payments being made on it, the mother decides to file a lawsuit against the doctor’s office instead. The doctor’s office is being charged with a white-collar crime known as health care fraud.

While health care fraud might not seem like a serious deal, as situations like this can be explained away by a simple mistake, a conviction for this charge is horrific. If it is a health care practice, the whole office can find itself facing a huge financial strain, putting it at risk of closing down. Nurses or doctors who are charged with health care fraud can find their license to practice revoked, and patients who are trying to scam the health care system can face jail time and hefty fines.

The defense attorneys at Gebhardt & Eppes, PLLC is dedicated to defending those who have been charged with crimes. Whether that is a white-collar crime or a violent crime, our team will stand by your side and be your advocate. We fully believe that every individual is innocent until proven guilty, which is why we work around the clock to ensure that your charge is either thrown out of court or reduced. Here is more information on our health care fraud services.


What Is Health Care Fraud?

Health care fraud is a type of white-collar crime that describes the actions of an individual or health care practice that is dishonestly filing health care claims to profit from the payments being received or to receive services. According to the FBI, tens of billions of dollars are lost every year to health care fraud. It is one of the leading causes of health insurance premiums rising, exposes individuals to medical procedures they may not need, and increases taxes.

There are various types of health care fraud, including those that are carried out by health care practitioners, insurance companies, and even the patients themselves. Prosecutions for health care fraud fall under the Federal False Claims Act.

What Is the False Claims Act?

The False Claims Act is a federal statute enacted in 1863 in response to defense contractor fraud during the Civil War. This act soon was expanded to include false claims for insurance companies and health care. Individuals who knowingly submit a false claim to a health care facility, insurance company, or the federal government are liable for double the damages along with a penalty of $2,000 per claim.

What Are the Different Types of Health Care Fraud?

Health care fraud can be broken down into two main types, health care practitioner fraud, and health care customer fraud. Here is a more detailed look into these two different types:

Health Care Practitioner Fraud

A doctor accepting a bribe.

Health care practitioner fraud describes when the physicians, nurses, or any other member of a health care team commits the following action:

  • Prescribing unnecessary medications that are covered or subsidized by health care so that they can be resold on the black market for a higher price
  • Filing the same claim multiple times
  • Filing a claim for medical services that were never given (this is also known as phantom filing)
  • Providing wrong details such as identities, dates, and descriptions of services
  • Modifying medical records
  • Wrongly billing a service that is not covered by the patient’s insurance 
  • Adding unnecessary treatments, procedures, or diagnoses to increase the claim amount
  • Using a commission system among members of the practice
  • Excluding certain patients from co-pays
  • Driving up the costs by billing each stage of a procedure separately (this is also known as unbundling)
  • Accepting kickbacks from a patient referral
  • Referring patients to service entities where the doctor has ownership or investment (this is also known as self-referrals)

Health Care Customer Fraud

Patients can also commit health care fraud by doing the following actions:

  • Selling their prescription drugs
  • Providing the wrong details when applying for programs or services
  • Forging prescription drugs
  • Claiming transport payments when used for other purposes not related to their medical treatment
  • Filing a claim using another person’s insurance card

What Are the Penalties for Health Care Fraud?

Health care fraud can be broken down into either a civil case or a criminal case.

Civil cases of health care fraud often result in the individual being forced to repay the cost of the claims or the cost of the denial of future claims. If a patient is charged with health care fraud and they are convicted, they can be barred from government health care programs. Health care professionals that are being charged with a civil case of health care fraud could face the state’s disciplinary board and potentially lose their license.

Criminal cases of health care fraud face heavier penalties. Texas health care fraud can range from misdemeanor charges or felony charges. The penalties will vary depending on the severity of the crime.

For example, if an individual commits health care fraud that falls under the False Claims Act, then they can face a penalty of federal prison time for five years along with a fine of up to $250,000. They may also find their license revoked and be excluded from government health care programs.

What Are the Possible Defenses Against Health Care Fraud?

A bunch of medical equipment around a legal gavel.

For an individual to be convicted of health care fraud, it has to be shown that the defendant had intent. The prosecution must prove that the defendant acted knowingly and willfully. Without the intention to deceive, however, an individual cannot be convicted of health care fraud. 

Depending on your situation and the kind of health care fraud you are being charged with, our team will change our argument to fit your case. There are many ways that an alleged fraud can be brought down to just a simple mistake and not an intentional act. For example, our team often uses the following:

  • The act was a mistake in the billing or the payment
  • Delegation of errors
  • Unqualified workers or employees in training made the mistake
  • Lack of worker oversight
  • Constantly changing rules in health care led to the mistake.

Don’t Wait Until It’s Too Late, Call our Fort Worth Health Care Fraud Lawyers 

Even if your charge is starting as a civil case, you will want to have a defense attorney on your side. Health care fraud is a slippery slope in the legal system, and can often lead to a charge being elevated to a more serious crime. Having a legal advocate on your side can ensure that you are being treated fairly by the prosecution and that your charge doesn’t get elevated. We are your voice in a court of law and will help show your side of the story. Contact our team today for more information on our health care fraud services or to schedule a consultation to go over the facts of your case. Don’t let your practice or yourself go down for a simple mistake.


Health Care Fraud FAQs

What Is Fraud in the Health Care Industry?

Fraud is when an individual knowingly gives false information that allows someone to get a benefit that is not allowed.

What Are Examples of Health Care Fraud?

Examples of health care fraud are as follows:
1. Billing for services that were not actually performed.
2. Upcoming or billing a more expensive service than the one the patient actually received.
3. Billing each stage of a procedure as if it were a separate procedure.

Additional Resources