Criminal defense lawyers specializing in allegations of healthcare billing fraud – nationwide criminal defense and consultation

Criminal defense in cases of healthcare billing fraud

A summons as a suspect, a search warrant for your practice, an inquiry from the Association of Statutory Health Insurance Physicians – the accusation of billing fraud usually hits doctors, dentists, pharmacists, nursing facilities and therapists suddenly and with considerable force.

Under criminal law, this allegation is generally prosecuted as fraud under Section 263 of the German Criminal Code (StGB) – an offense with complex requirements regarding deception, error, and harm. Particularly in the healthcare sector, it is crucial to understand that billing errors alone do not constitute a criminal offense. Whether criminal conduct has occurred depends largely on whether the billing complied with the relevant regulations and whether intentional misconduct can be proven.

Both of these often present a challenging question of proof – and this is precisely where effective criminal defense comes into play.

When is a Is there billing fraud in the healthcare sector?

Under criminal law, "billing fraud" is not a separate offense, but rather a term used in practice. Prosecution typically occurs under the fraud offense defined in Section 263 of the German Criminal Code (StGB).

The legal definition – in simplified terms – requires: 

1. a deception about facts (explicitly or implicitly)
2. an error caused by this at the recipient
3. a disposition of assets due to error 
4. a financial loss 
5. Intent with regard to all objective characteristics and the intention to obtain an unlawful financial advantage for oneself or a third party.

In the healthcare sector, this is particularly relevant: Even submitting an invoice can be considered implied fraud. The service provider thereby implicitly declares that the billing requirements are met – even if they do not explicitly confirm this.

The damages are determined according to social security law standards: The decisive factor is whether a claim for payment existed under the relevant social security regulations. If this was lacking – for example, because a service was not properly provided or was not billable – the sum paid out is considered the damages.

The relevant billing regulations include: The Uniform Assessment Scale (EBM), the Fee Schedule for Physicians (GOÄ), the Fee Schedule for Dentists (GOZ), and, in the inpatient sector, the DRG system. Errors or questions of interpretation in these regulations frequently form the basis for criminal charges.

Typical scenarios in healthcare billing fraud

The suspicion of billing fraud can be directed in particular against: doctors, dentists, psychotherapists, employees of hospitals, pharmacies, medical supply stores, physiotherapy and therapeutic practices, as well as nursing and care services.

Typical case groups are:

• Services not provided or provided incorrectly – e.g. so-called „air services“ or cases of upcoding.
• Violations of the obligation to provide services personally
• Status issues – e.g., when a doctor bills for services as a self-employed contracted physician, even though he is only an employee.
• Incorrectly assessed or non-billable services
• Care services not provided or provided without the required qualifications
• Violations of prohibitions on cooperation (e.g., inadmissible cooperation according to § 128 SGB V)

How is billing fraud detected? – Process and typical measures

Investigations rarely begin by chance. Common triggers include: 

• Internal tips or reports from current or former employees
• Inspections by the Medical Service (MD) of the health insurance funds 
• Announcements from the Association of Statutory Health Insurance Physicians or individual health insurance funds

The public prosecutor's office directs the investigation. Typical procedures include searches of offices and private residences, seizure of servers, data storage devices and patient records, questioning of employees, and obtaining expert opinions. Assets can be secured through asset freezes early in the investigation.

What are the penalties for billing fraud in the healthcare sector?

The statutory penalty for fraud (§ 263 of the German Criminal Code) ranges from a fine to five years' imprisonment. In particularly serious cases, the penalty is imprisonment from six months to ten years, for example, in cases of commercial activity, substantial financial loss (from €50,000 per victim), or commission by a criminal organization. If both commercial and criminal activity are committed simultaneously, the even harsher penalty range of § 263 para. 5 of the German Criminal Code applies (1–10 years). 

In addition to the main penalty, significant collateral consequences may also occur:

• Asset confiscation pursuant to Sections 73 et seq. of the German Criminal Code – often secured already during the investigation proceedings through asset seizure.
• Professional ban according to § 70 StGB
• Disciplinary measures, such as the revocation of the license to practice medicine 
• Claims for reimbursement by the cost bearers

Criminal defense by Galen Lawyers

The lawyers at Galen Rechtsanwälte advise and defend clients nationwide in white-collar and medical criminal law. We have forensic experience in complex economic proceedings and represent both individuals and companies.

An effective defense begins early and combines substantive legal review with consistent evidence gathering.

Our approach: 

In the first step, we secure your procedural position.

You should not make any statements regarding the matter without legal advice and without reviewing the case file. A hasty statement can create risks that are difficult to rectify later. After reviewing the case file, we will examine the allegations according to the elements of the offense under Section 263 of the German Criminal Code (StGB): What specific act of deception is alleged? Which billing rule is said to have been violated? Who is alleged to have been mistaken, and when? How is the damage calculated – and is this calculation contestable? What evidence supports the allegation of intent?

At the same time, we keep a close eye on the economic and professional legal dimensions. Where clawback claims or disciplinary action are threatened, a coordinated defense strategy is essential. Crucial decisions can be made, particularly during the investigation phase – for example, regarding searches, asset freezes, or the possibility of a pragmatic procedural solution.

Please feel free to contact us to schedule an appointment. We offer personal, discreet, and individualized consultations.