In Colorado, making false health insurance claims, using another person’s health care information, or submitting fraudulent claims is healthcare fraud. Filing a fraudulent health care insurance claim is a felony offense in Colorado, with penalties including up to 3 years in prison and fines of up to $100,000.

In this article, our Denver Colorado criminal defense lawyers will address:

• 1. What is health care fraud?
• 2. What are the penalties?
• 3. What are some defenses?
• 4. Is health care fraud a federal crime?
• 5. Related Offenses
• Additional Resources

1. What is health care fraud?

Health care fraud in Colorado generally involves insurance fraud. However, there may be additional penalties and criminal charges if health care fraud involves state or federal healthcare programs, like Medicare or Health First Colorado.

Under Colorado law, you commit health insurance fraud when you, with the intent to defraud:

• Present an application for a health insurance policy that contains false information or withholds material information resulting in insurance coverage;
• Make a claim for an injury that contains false material information or withholds material information;
• Participate in a staged car accident claiming injuries; or
• Make an oral or written statement in support of a medical insurance claim for payment, knowing the statement contains false information or withholds material information.

Health care fraud often involves medical providers fraudulently billing insurance companies or government medical services. This includes:

• Submitting duplicate claims for a single procedure,
• Billing for medical care or services that were never provided,
• Billing for patients who were never treated,
• Billing for more expensive services than were provided (“upcoding“), or
• Performing unnecessary surgeries or procedures.

2. What are the penalties?

Submitting a health insurance application with false information or failing to provide material information is a class 2 misdemeanor.¹ Penalties include:

• up to 120 days in jail and/or
• up to $750 in fines.

Other health care fraud, including filing a false claim or submitting a claim for fraudulent services, may result in class 5 felony charges. Penalties include:

• 1 to 3 years in prison (plus 2 years of mandatory parole) and
• a fine of up to $100,000.

3. What are some defenses?

In order for the prosecutor to prove you are guilty of health care fraud, they have to prove beyond a reasonable doubt that you intended to commit fraud. Possible defenses to health care fraud charges include showing that:

• You did not knowingly enter false information in your health insurance application;
• You did not intend to commit fraud when entering a false statement;
• Any duplicate or incorrect claims were submitted by mistake; or
• Another person was responsible for submitting false information.

4. Is health care fraud a federal crime?

Health care fraud is a federal crime under 18 U.S.C. 1347. Federal health care fraud includes:

• defrauding any health care benefit program, or
• obtaining any money or property by means of false representations.

The penalties for federal health care fraud include fines and imprisonment for up to 10 years. If health care fraud resulted in serious bodily injury, a conviction may result in up to 20 years in prison.²

5. Related Offenses

Identity Theft C.R.S. 18-5-902

In Colorado, it is a criminal offense to use another person’s personal or financial identifying information to obtain anything of value. Identity theft can be a felony or a misdemeanor.

Insurance Fraud C.R.S. 18-5-211

Making misrepresentations in an insurance application or filing a fraudulent insurance claim is a criminal offense. It can be a felony or a misdemeanor.

Forgery C.R.S. 18-5-102

In Colorado, altering a document with the intent to defraud is felony forgery. Under Colorado law, the crime of forgery in the first degree is a felony carrying:

• up to 3 years in prison and
• a fine of up to $100,000.

Additional Resources

To report fraud, refer to the following:

• How to Report Suspected Fraud – Colorado Department of Health Care Policy & Financing.
• Report suspected fraud or attempted identity theft – Connect for Health Colorado’s Office of Conflict Resolution and Appeals
• Report Medicaid Fraud or Abuse – Colorado Attorney General.
• Health Care Fraud Unit – U.S. Department of Justice.
• Report Fraud – U.S. Department of Health and Human Services.

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Legal References