As mentioned above, healthcare fraud is generally considered conduct or a scheme that is designed to cheat a government or private health insurance program.  There are a number of federal laws that target healthcare fraud which the government relies upon with regularity to pursue criminal charges. 

The main law which the government relies upon to pursue healthcare fraud charges is codified at 18 U.S.C. § 1347 and is plainly entitled “Health care fraud.”  Under this federal statute, a person that makes a false statement or a promise to defraud a health care program and who does so “knowingly or willfully” shall be guilty of a federal felony and can be punished by imprisonment of up to 10 years.  This is the most commonly used statute by federal prosecutors in pursuing healthcare fraud charges. 

When there are two or more defendants involved in a healthcare violation, the government can, and usually does, bring conspiracy charges under 18 U.S.C. § 1349. A conspiracy does not need to be successful nor does the goal of the conspiracy need to have been accomplished in order for the government to obtain a conviction.  The essence of a conspiracy charge is the agreement itself.  Thus, all the government needs to do to win a conspiracy charge is to prove there was an agreement to violate a healthcare fraud law.  A conviction under this statute can lead to a sentence of up to 10 years in prison. 

The government can also prosecute healthcare fraud under traditional mail and wire fraud statutes which are found at 18 U.S.C. § 1341 and 1343.  When a person uses the mails or some electronic means to further a fraud, including healthcare fraud, then the government can prosecute under these traditional statutes.  Each of these statutes carries penalties of up t0 20 years in prison which is far greater than the penalties under the specific healthcare fraud statute at 18 U.S.C. § 1347. 

Another commonly utilized federal statute is 18 U.S.C. § 287.  Under this law, a person can be prosecuted and imprisoned up to 5 years for making a false claim (e.g. invoice) for services to a government agency.  This statute is very commonly used in fraudulent billing cases where invoices are submitted for medical services never rendered or where the services rendered are exaggerated. 

Finally, under 42 U.S.C. § 1320a-7b, also known as the Anti-Kickback Law, it is illegal for a person to pay or receive a “kickback” (e.g. bribe, payoff, gratuity or other benefit) in relation to medical services or equipment paid for by a government sponsored health care program.  Stated another way, the law makes it illegal to knowingly and willfully offer, pay, solicit, or receive anything of value directly or indirectly to reward patient referrals for any item or service reimbursable by the federal health care program. The criminal penalties for violating this law include fines, imprisonment (up to 5 years), and exclusion from being able to further participate in the federal health care system.