Health Care Fraud Schemes

Health Care Fraud Schemes

Health care fraud can be carried out in a number of ways, and may involved complex and large-scale schemes. The Department of Justice (DOJ) estimates that health care fraud costs the United States tens of billions of dollars each year. Some estimate that costs exceed $100 billion a year.

Health Care Fraud Schemes

Health care fraud is a white collar crime and is committed when a person or organization defrauds the health care system in order to obtain funds or services. These complex fraud schemes can take various forms. The most common are:

  • Billing for medical services not performed.
  • Billing for medical services not medically necessary.
  • Billing for the same procedure multiple times.
  • “Upcoding,” which is the act of using an improper billing code to get paid for a more expensive procedure than was actually performed.
  • Billing for medical equipment that was never provided.
  • Billing for phantom patients.
  • Accepting kickbacks in exchange for referrals.

Medicare Fraud

Medicare fraud is the most common of all health care fraud prosecutions. It involves the investigation and prosecution of individuals and organizations who are accused of defrauding public health care systems, including Medicare and Medicaid.

Medicare fraud committed by health care providers can include any of the above listed fraud schemes. Medicare fraud committed by insured members is usually to obtain medical benefits to which they are not entitled, and may include providing false information on applications, lying about injuries or age, or committing identity theft by using another person’s name or social security number.

Aggressive Prosecution of Health Care Fraud

In response to the growing frequency and complexity of health care fraud schemes, prosecutors and law enforcement officials aggressively pursue dramatic punishments against those charged with the crime.

In 2009 the Health Care Fraud Prevention & Enforcement Action Team (HEAT) was created in an effort to enhance collaboration among agencies and combine tools and resources between the DOJ and investigative agencies. The number one stated mission of HEAT is: “To marshal significant resources across government to prevent waste, fraud and abuse in the Medicare and Medicaid programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars.”

Health Care Fraud Defense

Criminal charges for health care fraud are prosecuted aggressively. If you have been accused Medicare fraud you need an attorney experienced in handing health care fraud cases who can combat aggressive prosecutors.

As a former health care fraud prosecutor with the United States Attorney’s Office, Ashley D. Adams understands the tactics and procedures the government will use to obtain a conviction. She understands how prosecutors operate, and the best tactics to use to mount a strong defense against health care fraud allegations. Given her prior work, she also has a longstanding and positive relationship with the U.S. Attorney’s Office, the Attorney General’s Office, and the Department of Justice. Put Ashley D. Adam’s experience to work for you.

Contact us or call now (480) 219-1366 for a consultation.


The attorneys at Ashley D. Adams, PLC handles federal criminal cases throughout the United States, including Arizona, Oklahoma, Utah, and California.