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Texas Health Care Fraud Laws: Definition and Punishments

Criminal Law Blog by The Law Office of Greg Tsioros

Texas Health Care Fraud Laws: Definition and Punishments

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Health care fraud is one of the subcategories of standard fraud and carries with it a wide range of penalties that you could be charged with. While health care fraud is just one type of fraud, there are also many different types of health care fraud that a person can commit. Knowing more about what these are and the definition of health care fraud will give you a better understanding if ever you’re charged with health care fraud.


Texas Health Care Fraud Laws and Definitions

In essence, health care fraud is a crime derived from an intentional misrepresentation or deception about any type of health care that benefits the entity or individual in any way. A crime of this sort can also be classified as health care fraud if the deception benefits another party or entity. It typically occurs when the entity involved provides this false information to the insurer, usually involving a claim or even an application for a specific health insurance policy.

A person or entity can also be charged with health care fraud in the event that they have intent to defraud the actual insurer. This can be due to soliciting, paying, offering, or receiving a benefit from the processed claim and any money derived from it. Like all types of fraud, health care fraud is classified as a white collar crime and brings with it a wide array of penalties.

There are many examples of health care fraud. The most common example occurs when a person lies on their insurance claim in order to maximize the benefits received. While this is the most common form of health care fraud, there are many other examples. This includes everything from billing for services that were actually performed to altering bills or receipts.

Types of Health Care Fraud

The many examples of health care fraud are also related to the types of health care fraud. These types can be divided into consumer and provider fraud. When it comes to providers committing health care fraud, there are a myriad of types associated with this crime. The three most common types of provider fraud include unbundling, upcoding, and kickbacks. Unbundling refers to the act of billing each portion of a single procedure separately. Procedures and treatments are typically bundled in hospitals and doctor’s offices with the intent of saving the patient money.

There are instances where the medical provider will attempt to maximize profits by separating these services and acting as though they are owed multiple payments. Upcoding refers to the act of billing the patient for a more expensive service instead of the one that was actually performed on them. Kickbacks involve the act of paying an entity for patient referrals. All of these are clear types of health care fraud. For consumer health care fraud, the types include:

  • Forging a medical bill
  • Filing a claim for a medication or service that wasn’t actually received
  • Using the insurance card or coverage of another person
  • Medical identity theft where the other person is not aware that their identity is being used to obtain health care goods or services
  • Possible Defense Strategies

Anyone that’s been charged with health care fraud has a number of defense strategies that they can utilize. Health care fraud rests on the fact that the crime was intentional. If there was a lack of intent to deceive or defraud, the act wouldn’t classify as health care fraud. It might also have been a case of mistaken identity. In some cases, the person that actually committed the crime might not be the same as the person that was accused.

Being arrested for health care fraud in Texas is not always based on clear-cut evidence. The information or claim that the defendant made might indeed have been filled out correctly. If only some of the claim was false, this can also be used as a defense. The defendant would still retain liability for the invalid portion of the claim but would not be for the part of the claim that was actually valid.

Penalties For Each Type of Health Care Fraud

People that have been arrested for health care fraud in the state of Texas can be charged with a wide range of different penalties and punishments. This largely depends on the severity of the crime, as well as the amount of the claim in question. In the state of Texas, charges for health care fraud can range all the way from a misdemeanor to a felony. In some situations, the fraud will automatically call for a state jail felony, though this is only in cases where the fraud is extensive.

If you are charged with a state jail felony, the penalty rests between 180 days to two years of jail and/or a fine of up to $10,000. In every other case, the penalties range in severity. For instance, if the value of the claim was below $100, the crime is classified as a Class C misdemeanor. A Class C misdemeanor carries with it a fine of $500. A Class B and Class A misdemeanor charge is also possible if the claim is below the amount of $2,500. This will still usually result in a fine of some sort.

A state jail felony occurs when the claim is below $30,000 but above $2,500. After this, a person can be charged with a third degree felony, second degree felony, or first degree felony. A first degree felony occurs if the value of the claim was over $300,000 or if the act resulted in the harm or death of another person. When someone is charged for a first degree penalty, the penalties include anywhere from five to 99 years in prison and/or the possibility of a fine of up to $10,000. Requesting the aid of a defense attorney can assist in bringing these penalties down.

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