The Criminal Health Care Fraud Statute 18 US Code Section 1347 prohibits knowingly and willfully executing, or attempting to execute, a scheme to defraud any health care benefit program or obtain (by means of false pretenses, representations,or promises) any of the money or property owned by or under the custody or control of any health care benefit program.

Module VI Learning Outcome/ Objective

1. Display an basic understanding of the Criminal Health Care Fraud Statute and apply to fact scenarios.

Discussion Questions

Answer the following questions and state the legal reason for your answer

1. Mary is a licensed nurse practitioner and allows Dr. Smith to bill under her name? Is this legal or illegal?

2. Dr. Smith has the resident perform the significant part of the surgery and bills as though Dr. Smith performed the whole surgery? Legal or illegal?

3. Mary wants a face lift and Dr.Smith obliges and bills the patient because Mary's insurance does not cover the procedure. Legal or illegal?

4. A medical facility waives co payments and deductibles for the Medical Director's son. Legal or Illegal?