Types of Health Care Prosecutions In Federal Court

I. Types of Health Care Fraud

The types of “health care fraud” that you usually see prosecuted in federal court includes:

1. Medicare/Medicaid Fraud
   -Overcharging the patient for services
   -Prescribing unnecessary services or prescriptions
   -Diagnosing more severe diseases or conditions
2. Prescription Fraud
   -false representations to obtain prescription drugs
   -altered prescription substance and/or amounts
   -forged doctor’s name
3. Doctor / Pharmacist “Pill Mills”
   -prescribing more controlled substances than medically necessary
   -usually involves pain medication
4. Illegal Internet Pharmacies
   -on-line ordering capability for controlled substances
   -supposedly with a doctor’s prescription
   -in reality, no valid prescription needed
   -or prescriptions not verified
5. Overbilling / Code Manipulation
   -charging for services or procedures not given
   -using different or additional procedures for higher reimbursements
6. Mislabeling or Misbranding
   -misleading information on the labels
   -misrepresentation as to the substance in the container

II. Charges

Health care fraud cases are frequently charged as federal criminal offenses by the U.S. Attorney’s Office as:

1. Health Care Fraud – 18 U.S. Code §1347;
2. Conspiracy   – 18 U.S. Code §371;
3. Mail Fraud   – 18 U.S. Code §1341;
4. Wire Fraud   – 18 U.S. Code §1343;
5. Conspiracy to
   Commit Fraud   – 18 U.S. Code §1349.

III. Investigations and Indictments

Investigations are conducted by federal agents, which includes FBI, U.S. Postal Inspection Service, Health and Human Services Office of Inspector General, among others.

The United States Attorney’s Office prosecutes health care crimes in federal court, and the U.S. Attorney seeks Indictments through federal grand juries to begin the formal process of federal charges/case.