Federal Health Care Fraud – 18 U.S.C. § 1347

Laws, Penalties, Examples, Conspiracy Charges, and Defense Strategies

Federal health care fraud is a serious criminal offense involving schemes to defraud government or private health care benefit programs, including Medicare and Medicaid.

These cases are aggressively prosecuted because they involve the misuse of public funds and can impact patient care.

Under 18 U.S.C. § 1347, it is a federal crime to knowingly and willfully execute, or attempt to execute, a scheme to defraud a health care benefit program or to obtain money or services through false or fraudulent representations.

If you're dealing with health care fraud charges, having a skilled California criminal defense attorney from Esfandi Law Group by your side can really make a difference.

We're here to support you, so feel free to call us for a free consultation at (310) 274-6529 or reach out through our contact page anytime.

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What Is Federal Health Care Fraud?

Federal health care fraud is a criminal offense under 18 U.S.C. § 1347 that prohibits knowingly and willfully using false statements, misrepresentations, or deceptive practices to obtain money, services, or benefits from a health care benefit program such as Medicare or Medicaid.

At its core, health care fraud involves intentional deception directed at a health care program or insurer. The law applies broadly to individuals, medical providers, businesses, and anyone who participates in submitting or supporting fraudulent claims.

A sealed indictment is a formal criminal charge issued by a federal grand jury that is kept confidential until law enforcement is ready to act.

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Key Legal Elements of Health Care Fraud

To obtain a conviction, federal prosecutors must generally prove:

• A scheme or plan to defraud a health care benefit program existed
• The defendant acted knowingly and willfully
• False pretenses, representations, or promises were used
• The conduct was intended to obtain money, services, or benefits

These elements apply whether the fraud was successful or merely attempted.

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What Counts as a Health Care Benefit Program?

A health care benefit program includes any public or private plan that provides medical services, coverage, or payments. This commonly includes:

• Medicare and Medicaid
• Private insurance companies
• Employer-sponsored health plans

Because many of these programs involve federal funding or regulation, fraudulent activity often triggers federal jurisdiction.

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What Qualifies as Fraudulent Conduct?

Fraudulent conduct can take many forms and does not require complex schemes. It generally includes any intentional act designed to mislead a health care program in order to receive benefits or payments that are not legitimately earned.

This may involve:

• Providing false information to qualify for benefits
• Submitting inaccurate or misleading claims
• Misrepresenting services, treatments, or eligibility

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Important Legal Insight

A federal health care fraud charge does not require proof that the defendant knew the conduct was illegal. Prosecutors only need to show that the defendant knowingly engaged in deceptive conduct.

Additionally, the fraud does not need to be successful. Attempting to obtain benefits through false representations can be enough to support a charge.

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Simple Example

An individual applies for a government-funded health program that requires income below a certain level. Despite earning above the threshold, they intentionally report lower income to qualify and receive benefits. This conduct may form the basis of a federal health care fraud charge.

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Key Takeaway

Federal health care fraud involves knowingly using false or misleading information to obtain money, services, or benefits from a health care program. It is a broad federal offense that applies to both individuals and organizations and includes attempted fraud.

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Key Legal Elements of Health Care Fraud

To secure a conviction under federal law, prosecutors must prove:

• A scheme to defraud a health care benefit program existed
• The defendant acted knowingly and willfully
• False pretenses, representations, or promises were used
• The conduct was intended to obtain money, services, or benefits

These elements apply to both successful and attempted fraud.

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Common Examples of Health Care Fraud

Federal health care fraud can take many forms, ranging from individual eligibility misrepresentations to complex billing schemes involving providers and third parties.

Because health care systems rely heavily on documentation and electronic claims, even small misrepresentations can lead to significant federal charges when done knowingly.

Below are some of the most commonly prosecuted types of health care fraud:

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False Eligibility Representations

Providing inaccurate income, household, or financial information to qualify for government-funded health care programs or subsidies.

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Billing for Services Not Provided

Submitting claims for medical services, procedures, or visits that were never performed.

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Upcoding and Overbilling

Charging for more expensive procedures or higher levels of care than what was actually provided.

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Unnecessary Medical Services

Billing for tests, treatments, or procedures that are not medically necessary in order to increase reimbursement.

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Kickbacks and Referral Schemes

Offering or receiving payments, gifts, or incentives in exchange for patient referrals or participation in treatment programs.

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Falsified Medical Records

Altering or creating documentation to justify billing, treatment, or continued care.

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Duplicate Billing

Submitting multiple claims for the same service or billing multiple insurers for a single treatment.

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Prescription Drug Fraud

Issuing or billing for medications that are not needed, not provided, or improperly prescribed.

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Identity-Based Health Care Fraud

Using another person's identity or insurance information to obtain medical services or submit claims.

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Provider Fraud Schemes

Health care providers or organizations engaging in systematic billing fraud often involve multiple patients and repeated claims.

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Key Takeaway

Health care fraud includes a wide range of deceptive practices, from false eligibility claims to complex billing and referral schemes, all aimed at obtaining money or services from health care programs through misrepresentation.

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Real-World Example

An individual applies for a federal health care program that requires income below a specific threshold. Despite earning above the limit, they knowingly report a lower income to qualify.

After receiving benefits, the false representation forms the basis for a federal health care fraud charge.

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Health Care Fraud Conspiracy – 18 U.S.C. § 1349

Federal law also criminalizes conspiracy to commit health care fraud. Under 18 U.S.C. § 1349, a person can be charged if they agree with others to commit fraud, even if the scheme is not fully completed.

A conspiracy typically involves multiple participants working together to carry out fraudulent activities, such as recruiting patients, submitting false claims, or distributing proceeds.

Example of a Conspiracy Scheme

A group coordinates to recruit individuals to enroll in a federal health care program. These individuals are sent to a provider who submits claims for services that were not actually performed.

Participants receive payments for their involvement, while the provider collects reimbursement from the program.

All parties involved in the agreement, including recruiters, providers, and participants, may face conspiracy charges.

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Penalties for Federal Health Care Fraud (18 U.S.C. § 1347)

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Federal health care fraud penalties include up to 10 years in prison per count, with enhanced penalties of up to 20 years or life if injury or death occurs, along with fines, restitution, and asset forfeiture.

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Related Federal Crimes

Health care fraud is often charged alongside other federal offenses that address different aspects of fraudulent conduct:

Wire Fraud (18 U.S.C. § 1343)

Wire fraud is the use of electronic communications to submit false claims or conduct fraudulent transactions.

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Mail Fraud (18 U.S.C. § 1341)

Mail fraud is the use of postal services to send fraudulent billing or documentation.

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False Claims Act (31 U.S.C. §§ 3729–3733)

Civil liability for submitting false claims to the government.

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Anti-Kickback Statute (42 U.S.C. § 1320a-7b)

Prohibits financial incentives for referrals involving federal health care programs.

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Identity Theft (18 U.S.C. § 1028)

Use of another person's identity to obtain benefits or submit claims.

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Conspiracy (18 U.S.C. § 371)

Federal conspiracy charges involve an agreement between individuals to commit federal offenses, including health care fraud.

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Legal Defenses to Health Care Fraud Charges

Defending against a federal health care fraud allegation requires a precise, evidence-based strategy focused on the government's burden to prove intent, falsity, and connection to a health care benefit program.

Because these cases often rely on billing records, medical documentation, and electronic claims data, an effective defense challenges both the substance of the allegations and the evidence's development.

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Lack of Intent to Defraud

Health care fraud requires proof that the defendant knowingly and willfully engaged in deceptive conduct. A defense may show:

• Actions were the result of billing errors, coding mistakes, or administrative oversight
• Misstatements were unintentional rather than deliberate
• There was no purpose to deceive or obtain improper benefits

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Good Faith

A good faith defense focuses on the defendant's honest belief that their actions were lawful. This may include:

• Reliance on medical judgment or professional standards
• Belief that services were medically necessary
• Trust in billing staff, consultants, or compliance systems

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No Scheme to Defraud

A valid charge requires a structured plan to mislead a health care program. A defense may argue:

• The conduct reflects legitimate medical practice or business operations
• There was no coordinated or intentional fraudulent activity
• The issue is a regulatory or billing dispute rather than fraud

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Lack of Medical Necessity Dispute

Health care fraud cases often hinge on whether services were medically necessary. A defense may establish:

• Treatment decisions were based on professional medical judgment
• Differences in opinion do not equate to fraud
• Documentation supports the necessity of care

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Insufficient Evidence

The government must prove each element beyond a reasonable doubt. A defense may challenge:

• Incomplete or inaccurate billing data
• Misinterpretation of medical records
• Unreliable witness testimony or expert opinions

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Lack of Knowledge or Participation

In cases involving multiple individuals or organizations, a defense may show:

• No awareness of improper billing or documentation
• No direct involvement in claim submissions
• Limited role that does not support criminal liability

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Challenging Billing and Coding Practices

Health care billing systems are complex and prone to error. A defense may focus on:

• Coding ambiguities or industry standards
• Administrative mistakes rather than intentional fraud
• Systemic issues within billing processes

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Whistleblower Credibility Issues

Many cases originate from whistleblowers. A defense may examine:

• Potential bias or financial motives
• Inconsistencies in allegations
• Lack of firsthand knowledge

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Constitutional Violations

If evidence was obtained improperly, it may be excluded. A defense may challenge:

• Unlawful searches or seizures
• Improper subpoenas or investigative methods
• Violations of the defendant's rights during questioning

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Statute of Limitations

Federal charges must be brought within a defined time period. A defense may argue:

• Alleged conduct falls outside the allowable timeframe
• Delays in prosecution invalidate certain claims

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Key Takeaway

Legal defenses to health care fraud charges focus on disproving intent, challenging the existence of a fraudulent scheme, and attacking the accuracy, interpretation, and admissibility of the government's evidence.

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Why Early Legal Representation Matters

Federal health care fraud investigations often begin long before charges are filed. Early legal representation allows for:

• Protection of your rights during audits or investigations
• Strategic response to subpoenas and government inquiries
• Development of a proactive defense strategy

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Why Early Legal Representation Matters

Federal health care fraud investigations often begin long before charges are filed. Early involvement of a defense attorney can:

• Protect your rights during the investigation
• Prevent damaging statements
• Respond to subpoenas and audits
• Negotiate potential pre-indictment resolutions

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Frequently Asked Questions (FAQs)

What is federal health care fraud?

It is the intentional use of false information or deceptive practices to obtain money or services from a health care benefit program.

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Do I have to know the law to be convicted?

No. Prosecutors only need to prove that you knowingly made false statements, not that you knew the conduct was illegal.

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What is a health care fraud conspiracy?

It is an agreement between two or more people to commit health care fraud, even if the scheme is not completed.

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What are the penalties for health care fraud?

Penalties include up to 10 years in prison, or more if injury or death results, along with fines and restitution.

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Can I be charged if I did not receive money?

Yes. Attempting to commit fraud can still result in criminal charges.

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What should I do if I am under investigation?

Do not speak with investigators without legal counsel. Contact a federal defense attorney immediately.

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Speak With a Federal Health Care Fraud Defense Attorney Today

If you are under investigation or facing charges under 18 U.S.C. § 1347 or § 1349, taking immediate action is critical. Federal prosecutors build strong cases, but an experienced defense attorney can protect your rights and develop a strategy tailored to your situation.

Early intervention can substantially influence the outcome of your case. Esfandi Law Group is prepared to assist you.

Please schedule your complimentary consultation by contacting us at (310) 274-6529 or by utilizing the contact form available here.