Five Popular Health Care Provider Fraud Schemes

The Washington State Health Care Authority (WSHCA) provides information about common practices that might be Medicaid or health insurance fraud. The WSHCA urges patients to report suspicions of unethical behavior by health care providers. 

Doctors, hospitals, and other service providers should set up protocols to prevent these things from happening. If you, as a health care provider, get accused of Medicaid, Medicare, or other health insurance fraud, you should talk to a Seattle criminal defense attorney right away to protect your rights. Here are five popular health care provider fraud schemes:

Incorrect Coding

Accurate billing requires the use of accurate billing codes. The billing code determines the amount of compensation the health care provider can charge the insurer and patient. For example, a doctor cannot charge as much for a brief office visit as for an extended office visit. If a doctor routinely charges a patient a higher billing rate than deserved for more time than actually spent with the patient, the doctor might be committing fraud.

Also, using the billing code for a higher level of service than actually performed can be fraud. Let’s say that a clinic had maternity patients come into the office once a month for a basic check-up. The clinic then billed those visits as including more extensive workups than they were. Those “mark-ups” can be fraudulent billing practices.

Unnecessary Medical Services

When health care providers perform medical services that the patient clearly does not need, those practices can be fraud. Some examples of unnecessary services include:

  • Performing surgery like an appendectomy, tonsillectomy, or other operation on a perfectly healthy patient without any valid medical reason for the procedure.
  • Ordering diagnostic procedures like imaging studies or laboratory tests without an acceptable medical justification.
  • Pressuring the patient to come into the office for an unreasonable number of office visits and check-ups without a valid reason.

These are just a few examples of unnecessary medical services that health care might fraudulently provide to increase the cost to the patients and insurers.


A health care provider should not pay or accept financial incentives for referrals. Engaging in those schemes can remove a health care provider’s objectivity. The medical professional or facility might put the financial gain over choosing what is best for the patient. 

Often, a physician will refer a patient to a specialist for a consultation. In this situation, each doctor is allowed to charge a reasonable and fair amount for the value of the services that the doctor provides to the patient. Health care providers cannot legally take a percentage of the fees of the professional to whom they sent the patient.

Conflicts of Interest

The medical community is a tightly woven network with health care providers having multiple income streams. For example, a group of physicians might also own an imaging center that performs x-rays, MRIs, and CAT scans.

If the doctors who own the imaging center routinely send patients to their imaging center without disclosing their financial interest in the business, they might have a conflict of interest. If Medicaid or another insurer suspects that a significant number of the procedures were unnecessary, the health care provider could face adverse consequences in addition to the conflict of interest concerns.

Billing Medicaid, Medicare, or Other Health Insurance for Services not Provided

Sometimes stories hit the news about medical practices billing clients for hospital or office visits that never took place, surgeries they did not perform, and other obviously unethical behavior. Anyone can make an error on occasion and accidentally charge the wrong patient account. 

When a health care provider engages in those things intentionally and as a common business practice, the provider could face criminal charges, fines, and being stricken from the approved provider lists. The doctor or hospital also risks the loss of the professional license.

Allegations of any of these schemes can damage your professional reputation. A conviction could subject you to fines and jail time. With so much at stake, you do not want to delay in protecting yourself. A Seattle criminal defense attorney can advocate on your behalf if you get charged with health care fraud. Get in touch with our office today.

DISCLAIMER: This post is intended to share my perspective, insights, and some general information on various aspects of criminal cases. It is not legal advice and is not intended to substitute for legal advice. You should consult an attorney to obtain legal advice for your individual situation and case.