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Health Care Fraud

What Is Health Care Fraud?

Fraud in the nation’s health care system, including in the Western District of Michigan, results in estimated losses of more than one billion dollars every year from Medicare, Medicaid, and private insurance programs. Beneficiaries and other recipients of health care pay for these significant losses through higher premiums, increased taxes, and reduced services.

Health care fraud occurs when an individual, a group of people, or a company knowingly misrepresents or misstates something about the type, the scope, or the nature of the medical treatment or service provided, in a manner that could result in unauthorized payments. Examples of health care fraud include:

  • Billing for services not rendered or medical equipment not provided;
  • Falsifying certificates of medical necessity and billing for services or durable medical equipment that is not medically necessary
  • Billing separately for services that should be included in single service fees;
  • Falsifying plans of treatment or medical records to justify payments;
  • Misrepresenting diagnoses or procedures to maximize payments;
  • Misrepresenting charges or entitlements to payments in cost reports;
  • Fraudulent marketing of health care services and identity theft;
  • Forgery of prescriptions and diverting prescription medication; and
  • Soliciting “kickbacks” for the provision of various services or goods.

What Is the U.S. Attorney’s Office Doing About Health Care Fraud?

The U.S. Attorney’s Office is dedicated to prosecuting individuals, groups of individuals, institutions, and businesses that engage in health care fraud. In that effort, the Criminal and the Civil Divisions work closely with various law enforcement agencies and auditors of private insurance companies to identify and investigate misconduct.

When criminal prosecution is appropriate, a criminal complaint, a criminal information, and/or a grand jury indictment may be issued, identifying the alleged perpetrators and describing the nature and variety of the health care fraud charged. Depending on the, the court may order incarceration of the defendants, along with the payment of criminal fines and restitution for the victims.

In addition, the U.S. Attorney’s Office may pursue civil prosecution to obtain various forms of relief against the perpetrators of health care fraud, including awards of significant monetary damages (sometimes double or triple the actual amount of the false or fraudulent claims). Relief for these actions may include restraints on future actions, requirements to take future actions, or temporary suspensions or permanent debarments from participation in Medicare and related programs.

What Can You Do About Health Care Fraud?

In nearly all circumstances fiscal intermediaries and carriers for Medicare are required to send notices and explanations of benefits to Medicare users and patients. Review and verify the information on these documents. Question any entries or notations that are inconsistent with, or unrelated to, the actual health care services provided. Be especially attentive to notices and explanations that memorialize:

  • Payments for any medical services, treatment, supplies, or equipment that you did not receive;
  • Dates of service or provision of items that differ from the dates on which you actually received the service or items;
  • Payments for ambulance transportation that was not provided to you; and
  • Duplicate payments for the same service or items or for home medical equipment while you were hospitalized.

In addition, you should be cautious if a health care provider tells you that:

  • A test or certain equipment is “free” but your insurance number is required for “record purposes”;
  • The more tests given, the “cheaper” they are;
  • Your insurance company can be convinced to pay for the services rendered or the equipment provided; and
  • Your insurance company will pay for the services rendered or the equipment provided if an incorrect diagnosis or inaccurate description is communicated to it.

General Contact Information

If you believe that a health care provider has engaged in any of the conduct or practices described above, promptly contact the insurance carrier that sent the payment notice. Alternatively, contact one of the agencies or offices listed below to report the matter:

For Medicare Fraud:

The Inspector General’s Hotline: 1-800-HHS-TIPS (1-800-447-8477)
The Inspector General’s Web site:


Updated October 11, 2023