Common examples of healthcare fraud

Common examples of healthcare fraud

Last December, four New York City doctors were included in a group of individual and corporate defendants charged with defrauding publicly funded insurance providers like Medicare and Medicaid of millions of dollars. Their arrest drew a lot of press coverage and public ire.

In recent years, federal, state, and even local authorities have directed their efforts toward detecting fraudulent billing practices in hospitals, physicians’ offices, nursing homes, and other healthcare providers. Examples of medical care fraud include:

  • Falsifying patient records in connection with a claim for reimbursement is one of the most common acts of healthcare fraud.
  • Billing the government or an insurance provider for services that were never rendered. Also known as “phantom billing,” this fraud is normally detected when a medical professional seeks reimbursement for a visit but there is no record of that visit in the patient’s medical file.
  • Billing for unnecessary and expensive services. One example, albeit an extreme one, is seeking payment for open heart surgery when the patient only needed a minor operation to correct their condition. While such billings can sometimes be attributed to a code error (office administrators inputted a heart surgery code instead of the one for the actual procedure), they can also be evidence of fraud.
  • Making illegal referrals. The Stark Law prohibits doctors from referring patients to companies with which they have a financial relationship. Violations of this law are frequently treated as Medicare fraud.
  • Taking or offering kickback and bribes. Under the Anti-Kickback law, it is illegal for doctors, pharmaceutical firms, and similar companies to pay or otherwise offer compensation in exchange for referrals or recommendations.
  • Unbundling medical services. Medicare requires that certain services must be billed at lower, “bundled” rates. When a healthcare provider un-bundles them to submit a more lucrative invoice, they risk being charged with Medicare fraud.
  • Covering a service that is not normally covered. The government and insurance companies have “approved” medications and procedures that they cover. Some medical care providers code unapproved treatments as approved ones to earn more money.

Healthcare fraud is a troubling practice that increases the costs of medical treatment and passes the added expense on to patients. Still, there are instances of physicians and other providers being unfairly accused of illegal billing and offering or accepting bribes. Such claims can be career-destroying and need to be addressed head-on.

If you are a medical care professional who has been unjustly accused of fraud, then it is imperative that you contact an experienced New York criminal defense attorney. Whether the supposed fraud never happened or did happen due to genuine error, a well-prepared defense is your best chance at preserving the career that you worked so hard to achieve. Julie Rendelman is a highly sought-after New York City criminal defense attorney with over 20 years of legal experience. She is a former prosecutor and understands the New York criminal legal system. Ms. Rendelman offers free consultations and can be reached at 212-951-1232. Visit for more information.