9 Common Examples of Medical Fraud Claims

Healthcare fraud is a terrible crime that can be costly to taxpayers and injurious to innocent victims. It is so serious that it is a felony. But innocent mistakes or improper payments do not automatically constitute fraud. Medical fraud defense lawyers can expertly give protection by differentiating between malicious fraud and harmless errors.

9 Claims Medical Fraud Defense Lawyers Have Experience With

Efforts to combat and prevent fraudulent medical claims are essential to safeguard the integrity of the healthcare system, protect patients, and ensure the efficient allocation of healthcare resources. Healthcare fraud results in financial loss to insurance companies, healthcare programs, and individuals and erosion of trust in the system. There is also the very real danger of harming a patient directly or indirectly. Healthcare fraud is not victimless.

Even people who feel certain they are not guilty of fraud should take any and all healthcare fraud allegations seriously. Defense lawyers specializing in fraud will walk alongside you through the ins and outs of this tricky landscape and provide you with vital help and support. What constitutes healthcare fraud? Visit this page for some quick facts.

1. Billing Fraud

This occurs when healthcare providers submit false claims to insurance companies for services that were not provided, improperly documented, or providing unnecessary treatments for financial gain.

What It Could Look Like

A dentist submits claims to an insurance company for multiple procedures and X-rays done on a patient, even though only a regular routine cleaning was done.

2. Kickbacks

Kickbacks occur when healthcare providers receive payment or other incentives in exchange for referring patients or prescribing certain medications or treatments. These kickbacks can be illegal and are often intended to influence medical decision-making.

What It Could Look Like

A pharmacy pays a physician $4,000 to prescribe their new drug to patients, thus influencing the doctor’s treatment plan.

3. Double-Billing

Submitting multiple claims for just one performed service.

What It Could Look Like

A hospital submits two separate claims to an insurance company for the same surgery, double billing for both the surgeon’s and the anesthesiologist’s fees as if they were distinct procedures.

4. Phantom Billing

In this type of fraud, providers bill for services that were never performed. They may create fictitious patient records or inflate the cost of services.

What It Could Look Like

A clinic submits claims for physical therapy sessions that were never conducted for fake people. They even create false documents to show the progress of treatment.

5. Unbundling

Unbundling refers to the practice of billing for individual services separately instead of bundling them together as a discounted package. Providers may unbundle services that are normally bundled, solely to increase reimbursement rates.

What It Could Look Like

A lab performed a complete blood count on a patient but billed each component separately, so there were five individual bills instead of just one combined one.

6. Upcoding

This involves billing for a more expensive service than what was actually provided. For example, a bill may be for a more complex procedure instead of a simple one.

What It Could Look Like

A doctor bills for a double bypass when he only inserted a stent, so he gets higher reimbursement.

7. Falsifying Medical Records

Providers may alter or fabricate medical records to support false claims or to cover up fraudulent activities. This can include forging signatures, falsifying test results, or creating a fake diagnosis.

What It Could Look Like

A doctor adds symptoms of severe headaches to a patient’s chart even though the patient never complained about them. Then the doctor orders an MRI when it wasn’t really necessary.

8. False Certification

Providers may falsely certify patients as eligible for services or programs to receive reimbursement. This can include falsely certifying patients as homebound or needing skilled nursing care.

What It Could Look Like

A home health agency classifies a patient as homebound and in need of skilled nursing care to receive Medicare reimbursement, even though the patient is capable of performing daily chores just fine.

9. Overutilization

Overutilization refers to excessive or unnecessary medical services or tests being ordered or performed. Providers may engage in overutilization to generate more revenue, which inflates the cost of healthcare.

What It Could Look Like

A doctor routinely orders unnecessary diagnostic tests, like MRIs and CT scans, for patients with minor injuries to maximize billing and generate more revenue, despite the tests not providing any meaningful diagnostic value.

It’s important to note that this is not an exhaustive list, and the need for representation can arise in various other circumstances related to allegations or charges of medical fraud that may not be as clear-cut. The role of a defense lawyer is to provide legal advice, navigate the complexities of the legal system, and vigorously defend the doctor’s rights and interests during the proceedings. Remember, mistakes don’t automatically equal fraud.


Sanket Goyal is an SEO specialist at and is passionate about new technology and blogging.

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