The submission of false or misleading claims to a public or private health insurance program, or other deceptive conduct intended to obtain payment or benefit from a healthcare system to which the claimant is not entitled. Common forms include billing for services never provided, upcoding a service to a more expensive procedure than was actually performed, and kickback arrangements between providers and referral sources. It represents a significant source of loss to public health programs and private insurers in countries with public and private healthcare financing systems, and is prosecuted both as an offense against the insurer and, where public funds are involved, against the state.
Facts
Classification CodeIn the United States, health care fraud is defined and criminalized primarily by the federal health care fraud statute, 18 U.S.C. 1347, which covers schemes to defraud a health care benefit program or to obtain its money or property by false pretenses. 1 Typical PenaltyA first offense carries a fine or imprisonment of not more than 10 years; if the violation results in serious bodily injury the maximum rises to not more than 20 years, and if it results in death the offender faces any term of years or life imprisonment. 2 Elements of OffenseThe federal offense requires knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud a health care benefit program, or to obtain its money or property by false or fraudulent pretenses, representations or promises, in connection with the delivery of or payment for health care benefits, items or services. 2 Notable ExampleGynecologist Javaid Perwaiz was convicted in Virginia of performing unnecessary surgeries on women; a jury found him guilty of 23 counts of health care fraud and 30 counts of false statements related to health care matters, facing an effective 475 years, with a projected release date in 2070. 1 Jurisdiction VariationThe United States prosecutes health care fraud under a dedicated federal statute, 18 U.S.C. 1347, alongside civil recovery through the False Claims Act qui tam whistleblower provisions; the United Kingdom has no equivalent dedicated healthcare fraud offense and instead prosecutes fraud against the National Health Service under the general Fraud Act 2006. 3 Classification
Offense GradeSerious or Indictable Offense 1 Connections
Has Offense Grade
Entity-backed identity for the offense-grade enum value this offense already carries, resolved to a crime concept by an explicit value-to-entity map (phase 3 bucket conversion, docs\design_entity_backed_browse_buckets_20260928.md). The offense-grade fact itself stays on the offense unchanged.
In the Other Atlases
- Also in Geography Atlas: Europe, found in there.
- Also in Geography Atlas: North America, found in there.
Sources
1. Health Care Fraud (Wikipedia)
WikipediaLaws section, opening sentence
Under federal law, health care fraud in the United States is defined, and made illegal, primarily by the health care fraud statute in 18 U.S.C. § 1347
Examples section, US v. Javaid Perwaiz
He faced a maximum of 539 years (6,648 months) if convicted of all counts. The jury found him guilty of 23 counts of health care fraud and 30 counts of false statements related to health care matters. He faced 475 years.
View the Source 2. 18 U.S. Code section 1347 (Cornell LII)
Cornell Law School, Legal Information InstituteSection 1347(a)
Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice, (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services
Section 1347(a), penalty clause
shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.
View the Source 3. What is NHS Fraud (NHS Counter Fraud Authority)
NHS Counter Fraud AuthorityWhat is NHS fraud page, legal basisQuote, What is NHS fraud page, legal basis
making a false representation, failing to disclose information, or abuse of position, these are the three main ways of committing fraud as defined in legislation (Fraud Act 2006)
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