Much of the healthcare services that people receive these days are funded by another person for the patient. The payee could be a private healthcare insurer or a government healthcare program. The systems that process payments for such services are usually very complicated. The complication is what has led to the rise of crimes such as healthcare fraud. These are crimes that could be committed by patients, health insurers, and healthcare providers.

However, the confusing administration of medical bills is likely to cause authorities to accuse innocent individuals of the commission of healthcare fraud. Sometimes an honest mistake could be misinterpreted, leading to an innocent person serving time in jail. If you are facing healthcare fraud charges today, get in touch with Virginia Criminal Attorney. We are committed to helping people facing similar charges in Fairfax, VA, and Northern Virginia to fight for the reduction of their charges or freedom.

Legal Definition of Healthcare Fraud

Healthcare Fraud is a general term that includes several offenses such as drug fraud, medical fraud, and health insurance fraud. Health insurance fraud happens when a person or a company defrauds a government healthcare program or a health insurance company. There are several government healthcare programs in operation today, such as the United States' Medicare. The execution of this crime varies as the fraudsters try to dodge the law. Recovering damages from such an offense is possible through the use of the False Claims Act.

A good number of healthcare fraud cases are those that include government programs. That is why this crime is taken seriously and severely punished because it is a form of ripping the taxpayers off their hard-earned money. For that reason, prosecutors will do their best to find evidence against anyone that is arrested and charged with Healthcare Fraud. It may include individuals who may not have done anything wrong. It helps a lot to work closely with an experienced criminal attorney for your charges to be dropped to reduced to less-severe charges.

Elements of Healthcare Fraud

Just like other criminal acts, there are certain elements that a prosecutor must prove beyond reasonable doubt for the defendant to be found guilty of healthcare fraud. An offender will, for instance, be liable if they knew that the claim they were submitting was a duplicate of a fraudulent claim. A person could also be guilty if they prepared and submitted an application that they knew too well as a fraudulent claim.

Here is an example to best describe elements of Healthcare fraud.

An oncologist submits two claims to a patient's health insurer for one CT scan. He/she presents one of the claims as an individual application for a CT scan, and the other application includes the CT scan, amongst other medical tests the patients went through. If the oncologist is well aware that he/she submitted the two CT scans under separate claims, he/she will be found guilty of healthcare fraud. However, if the oncologist doesn't know the CT scan is included in the tests' invoice, he/she will not have knowingly submitted multiple claims. For that reason, he/she may not be found guilty of healthcare fraud

The main element for this offense will be the intent to commit fraud. The prosecutor must be able to prove that the defendant intended to defraud a government program or a medical healthcare insurer. If there is no proof for the defendant's intent, the court may not find the accused guilty of the charges.

Types of Healthcare Fraud in Virginia

As mentioned above, healthcare fraud in the state of Virginia takes many forms, and several healthcare providers can face charges of them. They include the following:

  • Doctors
  • Hospitals
  • Pharmacists
  • Home healthcare providers
  • Medical transport companies, which may consist of van/taxi service providers
  • Suppliers for durable medical gear such as wheelchairs, adult diapers, and prosthetics
  • Nursing homes
  • Rehabilitation providers
  • Companies offering home infusion treatment
  • Medical labs
  • Managed healthcare organizations such as PPOs and HMOs

Some of the common ways in which healthcare fraud is committed in the state are:

  1. Billing for Services Not Delivered

The most common form of healthcare fraud in the state of Virginia is submitting a claim for services that did not benefit a patient. Some of the services that a healthcare provider can defraud an insurer for include laboratory tests, X-rays, and medicine that were never given out. State laws stipulate that no person or company can submit a payment claim for any healthcare procedure or service that never benefited the policyholder. If there is proof of a submitted claim for services or goods never rendered, then the party that submitted the claim will face healthcare fraud charges.

Sometimes healthcare service providers up-code some medical processes. When a person is treated, they may not know the exact extent of the services they received. If payments for service delivery are made as per units of time, a fraudulent healthcare provider could expand the time to gain more than they should. A minor procedure can, for instance, be up-coded and billed as a more expensive or intensive service to cost the insurer more money.

  1. Paying a Kickbacks Patient Referrals

A kickback is an illegal type of payment that is intended to compensate a person for favorable treatment or improper services. Bribes could take many forms, including money, gifts, credit, and any other valuable item. The person who receives or pays a kickback is considered corrupt, as it makes it hard for the service provider to make an unbiased decision. 

Kickbacks are quite common in cases concerning healthcare fraud. Hospitals and doctors who receive payments from referring patients to other hospitals or doctors can face charges for fraud. The same goes for hospitals and doctors who give bribes to get referrals. The law makes it illegal for doctors to split fees in exchange for rent or to demand cash payments for referrals they make.

Patients should be able to trust that their healthcare providers are putting their health ahead of any business consideration.  Medicaid and Medicare providers make it unlawful for anyone to take a kickback for referring patients, prescribing certain drugs, or performing a particular procedure. Anyone that offers, solicits, receives or pays anything of value in exchange for referring or serving patients will face charges for healthcare fraud.

  1. Billing for Medical Tests that are Not Necessary

Billing unnecessary tests and procedures is an ancient type of healthcare scam by healthcare providers. The offense happens when a healthcare provider misrepresents the symptoms and diagnosis of a patient's record and then sending an invoice to the patient's healthcare insurer to receive higher reimbursement. A patient could. For instance, visit a doctor with just a common cold, but the insurer will receive an invoice for a medical condition such as pneumonia. Without realizing it, the insurer will pay more to the doctor or hospital than the cost for service their client received.

Sometimes the patient could even be treated for a medical condition they do not have just so the hospital could benefit more from their insurance provider. A dentist could, for instance, perform a root canal on a patient when the patient does not need it.

Some healthcare providers even apply additional charges to patients whose treatment is being paid for by an insurance provider. When such a patient, for instance, misses an appointment and gets charged. It does not happen to patients who pay out of their pockets. These patients could file charges against their healthcare providers for healthcare fraud.

  1. Submitting Multiple Claims for One Procedure

Double-billing, an insurance provider, will be taken as a serious offense if it was done to defraud the insurer. Again, this is a prevalent form of healthcare fraud. Some healthcare providers use tricks to charge for one procedure twice or even thrice, to benefit more than they should.

Double-billing could also happen when one healthcare provider receives payments for the same procedure from two insurers. For example, if a person conducting a study on drugs, bills their insurance company and consequently receives payments from a pharmaceutical company, they could be found guilty of double-billing. They will be prosecuted for healthcare fraud. 

There are many cases of two insurers, public programs, or both receiving bills for the same medical services. One has to be very careful when drafting invoices in order not to make one entry twice as this could be misinterpreted as treated as fraud.

  1. Submitting Undercharges and not Overcharges

The law makes it illegal for any healthcare provider to send an invoice to a healthcare insurer for past undercharged services, while not doing the same for overcharged services. There are several instances when healthcare insurers overcharge their services, but they do not submit bills for the same to insurance companies.

If, for instance, a patient visited a hospital on two separate occasions. On their first visit, they underwent some tests, and they got some drugs. On the second visit, they only saw a nurse. However, the hospital billed their insurance provider for the tests only on their first visit, forgetting the drugs. But on the second visit, the insurance paid for a doctor’s appointment, which is more expensive than a meeting with a nurse. The hospital will be charged with healthcare fraud if they billed the insurance company for the forgotten drugs but did not mention anything about the overcharged second visit.

Penalties Levied against Individuals Convicted of Virginia HealthCare Fraud

Healthcare fraud is a severe offense in Virginia. It can either be a criminal or civil case, with such punishments as prison time, fines and a requirement to pay restitution to the defrauded party. Anyone facing healthcare fraud charges in the state will benefit greatly from the help of a competent criminal attorney. Your attorney will help you fight against the charges you are facing to get the judge to drop the charges or at least reduce the charges for fairer penalties.

Civil charges for healthcare fraud in the state are pursued by healthcare insurers and are filed in Virginia courts. Penalties, in this case, will include a directive to pay restitution and fines. Sometimes the defendant could face charges for punitive damages in addition to the actual damages suffered by the insurance provider. Criminal charges, on the other hand, can bring about dire longstanding consequences for anyone that will be found guilty of healthcare fraud.

Common penalties that could be faced by anyone convicted of the offense include:

Prison Time

Healthcare fraud can be punished by up to 10 years of prison time in federal prison for every offense committed. If the crime led to death or serious bodily harm of a patient, the likely sentence would be between 10 and 20 years of imprisonment. Depending on the circumstances of the case, the offender could face charges for grand larceny, punishable with up to 20 years of incarceration.


Individuals found guilty of healthcare fraud in Virginia can also be subject to fines that could amount to $250,000 per offense. An organization that makes a false claim can be fined an amount of a maximum of $500,000 for every offense.  Any organization that conspires to make false healthcare claims can face charges for several counts of healthcare fraud. It means that they could face charges for millions in fines. If an individual suffers a Virginia grand larceny conviction, they could face charges for at least $2,500 in penalties for every offense they have committed.

Payment of Restitution Fees

Sometimes, the judge could order the defendant to reimburse all the money that they obtained illegally as a result of healthcare fraud.


Anyone that is facing a healthcare fraud conviction in Virginia could also face probation. Sometimes the defendant could get a reduced prison sentence and then get released on parole. In both cases, the defendant's freedom will be limited. Probations for such offenses could last for months or years, depending on the severity of the crime. A defendant can only be granted parole if they have served at lets one-third of their sentence.

When on parole or probation, the offender will receive specific conditions from the court, which they must act in accordance with. Such terms will include maintaining a regular job, avoiding criminal conduct and reporting to a probation officer from time to time. Failing to honor those conditions may call for revocation of the probation/parole, resulting in incarceration.

Possible Legal Defense against Virginia Healthcare Fraud Charges

From the penalties listed above, it is clear that healthcare fraud is among the most severely punished offenses in the state of Virginia. For that reason, it is advisable for anyone facing such charges to have a competent criminal defense attorney by their side. Fortunately, there are several defense strategies that your attorney can use to help with your case. Some of these are:

  1. Lack of Intent

The intent to defraud a healthcare insurance company or a government program is the main element of this offense. If there is no evidence that the defendant had the resolve to defraud the insurer or program, then the court may not find them guilty of the offense. Lack of purpose is a common defense strategy for most fraud charges. If the prosecutor is not able to prove intent, then the accused may be exonerated of the fraud charges. In addition to that, your criminal defense attorney can try to convince the court that, though you acted the way you did, your intention as not to defraud the insurance provider.

  1. Mistake of Facts

As mentioned above, a person can be falsely accused of healthcare fraud because of the nature of this offense. It is possible to, for instance, submit two claims for the same procedure, without meaning to do so. A person can only be convicted of fraud if they are well aware that their actions are fraudulent.  Note that healthcare insurance procedures and medical billing are very complicated. For that reason, an intelligent and very experienced professional can make a mistake in the billing process.

If there is proof that you were misguided about a particular crucial fact, you may not be aware that the claim you submitted was fraudulent. It will automatically mean that you did not commit the offense and should, therefore, be set free.

Find a Virginia Criminal Attorney Near Me

Healthcare fraud charges are not very easy to fight, especially if there is substantial evidence against the defendant. However, a competent criminal attorney working by your side will make a significant difference in the outcome of your case. At Virginia Criminal Attorney, we deal with all types of fraud cases, including healthcare fraud. Our commitment is to help our clients with the best advice and proper defense against the charges they are facing. Through our competence, we could help convince the judge to either reduce your charges or drop them altogether. Call us at 703-718-5533 if you are in Fairfax, VA, and Northern Virginia and let us take charge of your legal defense.