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Health Care Crimes

Insureds have an obligation to be truthful when dealing with their insurers in relation to their claims under insurance policies. However, insureds sometimes attempt to submit fraudulent bills in order to recover under their health insurance policies. In response to such actions, federal legislation was passed to make certain acts related to health care claims illegal.

Health Care Fraud

The Kassebaum-Kennedy Act created the crime of health care fraud, which is defined as the willful attempt or execution of a scheme, in connection with the delivery of a payment for health care benefits, items, or services, to defraud a health care benefit program or to obtain, by false or fraudulent means, the money or property of a health care benefit program.

Federal Health Care Offenses

An insured commits a federal health care offense if he commits or conspires to commit one of the following crimes in relation to a health care benefit program: making false, fictitious, or fraudulent claims or statements; conspiring to commit an offense against or defraud the United States; theft or embezzlement from an employee benefit plan; theft or bribery concerning programs that receive federal funds; mail fraud; wire fraud; and offers, acceptances, and solicitations to influence employee benefit plans.

Other federal health care offenses include an insured’s violation or conspiracy to violate federal legislation that prohibits a person from knowingly and willfully embezzling or stealing any money or property of a health care benefit program. Other legislation prohibits the making of false statements related to a health care benefit program by falsifying, concealing, or covering up a material fact or knowingly making any materially false, fictitious, or fraudulent statements, representations, or writings in connection with the delivery for payment for health care benefits, items, or services.

An insured or other person may also be guilty of obstructing any process of investigation related to federal health care offenses.

Copyright 2012 LexisNexis, a division of Reed Elsevier Inc.