Health care fraud is not often talked about, but it is a serious white-collar crime. It is a crime that affects everyone and results in tens of billions of dollars in losses per year.
Health care fraud causes a lot of problems, such as increases in health insurance premiums, exposure to unnecessary medical procedures, and increased taxes. However, it does not seem to be going away anytime soon. From 2020 to 2024, healthcare fraud increased by almost 20%.
Health care fraud can be perpetuated by anyone. Patients, marketers, suppliers, corporate executives, and even medical providers may engage in this crime because there is so much money in the health care industry.
Common Types of Health Care Fraud
Health care fraud involves knowingly submitting false or misleading information to obtain improper payments or benefits from health insurance programs such as Medicare, Medicaid, or private insurers. Some of the most common types include:
- Billing for services not rendered: Charging insurers for procedures, tests, or visits that never occurred.
- Upcoding: Billing for more expensive services or procedures than were provided.
- Unbundling: Separating procedures that should be billed together to increase reimbursement.
- Kickbacks: Offering or receiving payments or incentives for patient referrals or services.
- False diagnoses: Misrepresenting a patient’s condition to justify unnecessary treatments or tests.
- Duplicate billing: Submitting multiple claims for the same service.
- Phantom billing: Creating fake patients or services to generate fraudulent claims.
- Prescription drug fraud: Illegally prescribing, altering, or diverting medications for profit.
- Identity theft: Using stolen patient information to submit false insurance claims.
What are the Consequences?
Health care fraud in South Carolina can result in criminal, civil, and administrative penalties, depending on the nature of the offense, the amount involved, and whether the case is prosecuted under state or federal law.
Under South Carolina law, Medicaid and medical assistance fraud is generally classified as a Class A misdemeanor. Upon conviction, penalties may include up to three years in prison and up to $1,000 in fines per offense. Each false claim can be charged as a separate offense.
More serious cases involving large dollar amounts, repeated conduct, or conspiracy may lead to felony charges, especially if prosecuted federally.
In addition to criminal charges, civil penalties may be involved. The South Carolina Attorney General may seek treble damages (three times the amount of overpayment), civil penalties of up to $2,000 per false claim, and full restitution of improperly obtained funds.
Health care providers may also face administrative sanctions such as:
- License suspension or revocation.
- Exclusion from Medicaid or other government health care programs.
- Additional regulatory fines and sanctions.
Contact Us Today
Health care fraud is not a victimless crime. It is taken very seriously, especially at the federal level. It is considered a white-collar crime, so there is a lot at stake if you have been accused.
If you are the subject of an investigation, you need legal help right away. That is where the Greenville criminal defense attorneys from Watson Fowler Attorneys at Law come in. We will work to minimize your penalties. To schedule a consultation, contact us via (864) 668-5609 or online here.