Health Care Fraud Elements of the Offense

Reading an indictment under 18 U.S.C. § 1347 is not the same as understanding what the government has to prove at trial. The narrative in a charging document describes conduct across years and many claims. The elements are far narrower, and a jury is asked about each one separately.

This page sets out those elements as they are structured for a federal jury: the scheme itself, its connection to health care benefits, the materiality of what was represented, and the state of mind required. Element definitions evolve through decisions and through jury instructions, so confirm the current formulation for the charging district with counsel before relying on any summary, including this one. To discuss how the elements apply to a particular indictment, call (888) 437-7747.

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A Scheme or Artifice to Defraud, or to Obtain Money by False Representations

Section 1347 has two branches. The first is a scheme or artifice to defraud a health care benefit program. The second is a scheme to obtain money or property owned by, or under the custody or control of, such a program by means of false or fraudulent pretenses, representations, or promises. A scheme is a plan or course of conduct, and the government does not have to show that every claim in a practice was false. It has to show a plan whose object was to obtain money the program would not otherwise have paid, and it usually alleges specific executions of that plan as separate counts.

Connection to the Delivery of or Payment for Health Care Benefits

The scheme must connect to the delivery of, or payment for, health care benefits, items, or services. This element does most of the work of separating section 1347 from general fraud statutes, and in practice it is rarely contested where billing is involved. It matters more at the margins: in cases about marketing arrangements, data sales, staffing companies, or financing structures, where the alleged conduct sits several steps away from a claim. The term health care benefit program is not limited to Medicare, Medicaid, and TRICARE, and commercial insurance plans can fall within it.

Materiality

A false representation must be material, meaning it has a natural tendency to influence, or is capable of influencing, the decision of the payor. Materiality is what separates a genuine fraud theory from a paperwork violation. It is measured against how the program actually made payment decisions, not against how a compliance manual says it should have. Where a payor knew of the practice and continued paying, or where the requirement had no bearing on coverage, this element is where a defense concentrates. It is proved and disproved largely with payor records.

Knowingly and Willfully

The government must prove that the defendant acted knowingly and willfully. Knowledge means the act was not a mistake or an accident. Willfulness adds a further requirement about the defendant’s awareness that the conduct was unlawful, and the precise formulation matters enough that it should be checked against the instruction the court will actually give. Section 1347 also contains a provision addressing how much a defendant must know about the section itself; read it in the current statutory text rather than in a paraphrase. Good faith, honest mistake, and reliance on qualified advice all operate against this element rather than against the others.

Frequently Asked Questions

What counts as a scheme or artifice to defraud?

A scheme is a plan or course of conduct intended to deprive a program of money or property through deception. It does not require a written agreement, a formal structure, or more than one participant, and it does not require that every claim submitted was false. The government generally alleges a pattern and then charges individual executions of it as counts. The defense position is often that what the indictment calls a scheme was a business practice with disputed billing, which is a question about intent rather than about structure.

Does the government have to prove a patient was harmed?

No. Section 1347 is a fraud offense directed at the program and its money, so proof of physical harm to a patient is not an element. Harm can matter in other ways. It can support the government’s theory that services were unnecessary, and it can affect sentencing. Its absence is worth establishing for that reason. But a defense built only on the proposition that patients were treated well does not answer the element the jury is actually asked about.

What is a health care benefit program?

The term covers public and private plans that provide medical benefits, items, or services, so it reaches beyond Medicare, Medicaid, and TRICARE into commercial insurance. That breadth is why investigations that begin with government program claims often expand to private payors once agents hold the complete billing picture. It also means a provider who does not participate in federal programs is not outside the statute. Whether a particular plan qualifies is a legal question worth checking against the statutory definition in a specific case.

Does the claim have to be paid for the offense to be complete?

Execution of the scheme is what the counts charge, and payment is not required for the scheme to exist. Denied and unpaid claims can still be alleged, and they frequently appear in the intended loss figure at sentencing even though no money changed hands. That distinction matters when the practical picture and the legal picture diverge, because a provider who was paid very little can still face a large intended loss calculation built from what was submitted.

What does willfully add to knowingly?

Knowingly addresses whether the act was deliberate rather than accidental. Willfully addresses the defendant’s understanding that the conduct was unlawful, and courts formulate that requirement with some variation. Because the formulation drives the good faith defense, the instruction the court intends to give is worth litigating rather than assuming. Confirm the current standard in the charging district with counsel, because jury instructions are revised and the difference between formulations can decide a case built on ambiguity in coverage rules.

Is conspiracy charged separately from the substantive offense?

Frequently. A conspiracy count under 18 U.S.C. § 1349 can accompany substantive section 1347 counts, and it changes the evidence that comes in, because acts and statements of alleged co-conspirators may be admitted against a defendant who never made them. It also broadens the relevant conduct considered at sentencing. Defending the conspiracy count therefore often matters more than defending any individual execution, and it usually turns on what the client actually knew about what other participants were doing.

Working With Law Offices Of SRIS, P.C.

Element analysis is where a health care fraud case is either narrowed or lost. Reading the indictment against the instructions the court will give, and against the records behind each charged execution, is what shows whether the government has a fraud case or a billing dispute.

Mr. Sris, Owner and Founder of Law Offices Of SRIS, P.C., is a former prosecutor and is admitted in Virginia, Maryland, the District of Columbia, New Jersey, and New York. The firm has been practicing since 1997. Mr. Sris and the firm’s Of Counsel attorneys handle criminal defense matters across those jurisdictions, which matters in federal practice because a single investigation frequently reaches conduct, witnesses, and records in more than one state. Mr. Sris brings a background in accounting and information systems from George Mason University, applied to complex financial and technology-related cases.

The firm serves Northern Virginia from 1655 Fort Myer Dr, Suite 700, Room 719, Arlington, VA 22209 and central Virginia from 7400 Beaufont Springs Drive, Suite 300, Room 395, Richmond, VA 23225. By appointment. Call (888) 437-7747 to schedule. Request a consultation. Reach our location at (888) 437-7747.

This page provides general information about the elements of health care fraud under 18 U.S.C. § 1347 and does not create an attorney-client relationship. Case results depend on a variety of factors unique to each case. Results may vary.

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These are the elements the government must prove. Our page on health care fraud charges covers the offence as a whole.