Federal health care fraud is charged under 18 U.S.C. § 1347, which reaches a scheme to defraud any health care benefit program — including a scheme to obtain money or property from one by false or fraudulent pretenses. Health care investigations are typically parallel from the outset: a criminal inquiry alongside a civil False Claims Act exposure under 31 U.S.C. § 3729, and often an administrative process as well.
Waxman Litigation acts for companies and their boards. Seth B. Waxman spent 13 years as an Assistant United States Attorney in the District of Columbia, roughly eight of them on fraud and public corruption.
What does the statute say?
Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice— (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title ), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both. (b) With respect to violations of this section, a person need not
18 U.S.C. § 1347
The statute is written around a scheme, which is why investigations focus on billing patterns and internal communications rather than any single claim.
Why these cases run on two tracks at once
The same conduct can support a criminal charge under § 1347 and civil liability under the False Claims Act, 31 U.S.C. § 3729. Decisions taken in one track affect the other, which is why they are managed together — see parallel criminal and civil proceedings.
| Track | Statute | Brought by |
|---|---|---|
| Criminal | 18 U.S.C. § 1347 | Department of Justice |
| Civil | 31 U.S.C. § 3729 | United States, or a relator under § 3730(b) |
| Obstruction (separate exposure) | 18 U.S.C. §§ 1001, 1519 | Department of Justice |
What a company should do first
Preserve records before anything else. 18 U.S.C. § 1519 makes destroying or concealing records with intent to impede a federal matter a separate offense carrying up to 20 years — and it applies even in contemplation of a matter. Statements to investigators carry their own exposure under § 1001.
Frequently asked questions
Is a billing error health care fraud?
§ 1347 is written around a knowing and willful scheme to defraud. Whether particular conduct meets that standard is fact-specific and is exactly what an investigation examines.
Can the company face civil and criminal exposure at once?
Yes. Health care matters commonly run as parallel proceedings — criminal under § 1347 and civil under the False Claims Act.
What is the first step on receiving a subpoena?
Preserve records and take advice before gathering documents or interviewing staff.
Does cooperating help?
Cooperation decisions have real consequences in both tracks and should be made deliberately with counsel, not reflexively.
Who can be charged under the health care fraud statute?
Anyone who executes the scheme, not only the billing entity. 18 U.S.C. § 1347(a) reaches whoever knowingly and willfully executes or attempts to execute a scheme to defraud a health care benefit program, and § 1347(b) provides that a person need not have actual knowledge of the section or specific intent to commit a violation of it.
When does the government’s time to bring a case expire?
On two different clocks. Criminally, 18 U.S.C. § 3282(a) requires the indictment to be found within five years after the offense was committed. Civilly, 31 U.S.C. § 3731(b) allows six years from the violation, or three years from when the responsible government official knew or should have known the material facts, capped at ten years — whichever is later.
Where is the decision to exclude a provider actually made?
Not in the courtroom. Exclusion under 42 U.S.C. § 1320a–7(a) is imposed by the Secretary of Health and Human Services as a separate administrative consequence of a qualifying conviction, which is why a resolution of the criminal case does not by itself settle the provider’s participation.
How is early self-reporting credited on the civil side?
By capping the multiplier. 31 U.S.C. § 3729(a)(2) allows a court to assess not less than double damages rather than treble where the person gave investigators all the information they knew within 30 days of first obtaining it, fully cooperated, and did so before any action had commenced and without actual knowledge of an investigation.
How much does an exclusion cost a provider?
At least five years. For a mandatory exclusion under 42 U.S.C. § 1320a–7(a), § 1320a–7(c)(3)(B) sets the minimum period at not less than five years — a consequence that frequently outweighs the fine, because it reaches the organization’s ability to be paid at all.
Sources and legal authorities
General information about federal law, not legal advice, and not a prediction of any outcome. Federal criminal exposure turns on facts this page cannot assess. If your company has been contacted by investigators or has received a subpoena, take advice before gathering documents or interviewing staff.
Related: White-Collar Defense · False Claims Act Defense · Parallel Criminal & Civil Proceedings · Government Subpoenas · Internal Investigations. Call (301) 901-3109 or use the contact page.