Common types of health care fraud

When people think of white collar crime, they often think of giant embezzlement schemes, computer fraud or even insider trading. Another type of white collar crime is health care fraud. In some cases, health care providers, such as doctors, file fraudulent insurance claims on patients in order to collect more income. In other cases, individual health care consumers commit health care fraud.

Charges for health care fraud in Texas can have serious consequences, including fines, court fees and jail time.

Billing practices

In some instances of health care fraud, a medical provider will bill patients and insurance carriers for procedures that he or she did not actually perform.

False diagnosis

Another strategy for committing health care fraud is to falsify a patient’s diagnosis. A medical professional might do this to provide justification for tests, surgeries and other health care that is not truly necessary.


Sometimes, a medical professional will misrepresent a procedure in order to obtain an approval from the patient’s insurance carrier. For example, many insurers do not cover certain cosmetic procedures unless they are medically necessary.


When a medical professional “upcodes” a procedure, he or she is billing the patient or insurance company for a procedure that costs more than the one that the doctor actually performed.


Unbundling occurs when a medical provider bills separately for each stage of a procedure as though there were multiple procedures occurring, instead of just one.


Another form of medical fraud is receiving kickbacks for patient referrals. For example, if a pharmaceutical company pays a doctor to prescribe a high-cost medication to patients, then the doctor might face a health care fraud charge.

Waiving co-pays or deductibles

If a medical practice waives a patient’s co-pay or deductible and bills the insurance company at a higher rate to make up for the difference, this could also lead a health care fraud charge.

Consumer fraud

There are several types of consumer health care fraud that are fairly common. For example, if an individual files a claim for medication or services that he or she never received, then a criminal charge for health care fraud might result. Also, forging receipts, altering bills, or using someone else’s insurance are types of health care fraud.

If you are facing a charge for health care fraud, it is important to remember that you still have rights and options. With a strong defense, you might be able to successfully fight back against criminal charges for fraud.