5 Examples of Medical Fraud

5 Examples of Medical Fraud

March 20, 2024

Medical fraud is a significant concern in the healthcare industry, costing patients, insurance companies, the government, and innocent healthcare providers millions every year. Fraud involves using illegal practices to extract money or assets deceitfully from healthcare programs, insurance companies, government insurance like Medicare, and patients. If you've been accused of medical fraud, the consequences are serious, and contacting medical fraud lawyers right away is the best way to protect yourself.

5 Examples of Medical Fraud

Billing Fakes

This type of fraud involves billing for services that were never performed, significantly exaggerating the complexity of procedures, or charging for unnecessary treatments. For example, billing for a Level 5 office visit instead of a Level 3 for a routine checkup falls under this category. This violates the Texas Deceptive Trade Practices-Consumer Protection Act and the Texas Penal Code and can potentially lead to civil lawsuits and criminal charges.

If you received accusations related to billing, carefully review your records and seek legal counsel right away to assess the specific claims and consider potential defenses. Transparency and cooperation will help you here.

Kickbacks and Quid Pro Quo

This type of fraud involves accepting financial or any other form of incentive, like gifts or trips, in exchange for referring patients to specific services, prescribing certain drugs, or working with certain laboratories. This creates a conflict of interest, prioritizing profit over patient needs. This directly violates the Anti-Kickback Statute of the Texas Health and Human Services Code as well as federal law and can lead to severe penalties, including license suspension or revocation, as well as criminal prosecution.

For example, a clinic might be implicated if doctors there have been receiving gifts from a pharmaceutical company for prescribing specific drugs, regardless of patient need or when good generic options were available. If you face accusations related to kickbacks, immediately cease all practices that could be in any way construed as taking a kickback, and seek legal counsel immediately. Disclosing any past involvement and cooperating with investigations might be crucial here, so discuss with your lawyer the best way forward.


This type of fraud happens when you bill for each individual component of a single, bundled procedure as if they were separate services, which inflates the cost and misrepresents the actual procedure or procedures that were performed. This is known as unbundling. Federal and Texas law both address unbundling, and this action can lead to civil lawsuits and professional disciplinary actions.

If you received accusations related to unbundling, review your coding practices and billing systems to ensure compliance with proper bundling codes. Consult with your coding specialists, as well, and make sure you talk with a lawyer who can provide you with specific advice based on experience in Texas and federal health fraud laws. Learn more here about common questions about fraud.

Upcoding and Downcoding

This fraud happens when a healthcare provider or institution intentionally misrepresents the level of service provided. The scheme involves billing for a more expensive procedure than was actually performed (upcoding) or a less expensive one than was warranted for the patient's symptoms (downcoding), and both are fraudulent practices. For example, a cardiologist might be charged with performing unnecessary heart surgeries, a practice that not only inflates bills but also endangers patients' lives.

Both federal and Texas law criminalize upcoding and downcoding, and there are serious potential civil and criminal repercussions for this type of fraud. If you face accusations related to coding inaccuracies, carefully review your medical records and ensure your coding practices adhere to all the guidelines. It may be possible to show that you've made simple errors rather than deliberately misrepresented the services provided, and this is more common than it might seem due to the complexities of medical codes. Support from coding experts and your lawyer can help you assess the situation and your potential defenses.

Phantom Patients and Fabricated Services

Inventing patients and falsifying medical records to submit fraudulent claims for non-existent treatments is a severe form of fraud. This can be considered a type of forgery, and other fraud-related statutes on the federal and state level may be used to prosecute such a case.

There are significant criminal penalties here, and this is a serious allegation requiring immediate legal representation. Do not engage in any activity that could further compromise your situation, get legal help, and cooperate fully with any legal proceedings.

Getting Help From Experienced Medical Fraud Lawyers

Being accused of medical fraud is a serious matter under both federal and Texas law, with significant legal and professional implications. It's vitally important that you understand the specific nature of the accusation, whether it's billing fraud, unnecessary procedures, prescription fraud, falsification of records, or kickbacks, and that you know what steps to take to defend yourself.

If you face accusations of medical fraud, seeking representation from qualified legal counsel specializing in healthcare law is your best course of action. 

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