18 USC 1035 — False Statements Relating to Health Care Matters

18 USC 1035 makes it a federal crime to knowingly and willfully make a materially false statement — or to falsify, conceal, or cover up a material fact — in any matter involving a health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services. A conviction carries a fine and up to 5 years in federal prison per count. In practice, 18 USC 1035 is most often charged alongside health care fraud, where the false statement counts add charges, broaden the alleged scheme, and strengthen the government’s overall case.

This page explains what 18 USC 1035 prohibits, the elements the government must prove, the penalties, the statutes it travels with, and how these charges are defended. It is a plain-English legal reference for anyone facing a health care false statement allegation in California. For how we defend these matters, see our federal health care fraud defense page.

Summary of the Statute

Enacted as part of HIPAA in 1996 — the same law that created the main health care fraud statute — 18 USC 1035 was designed to reach false statements specifically in the health care context. It is the health care counterpart to the general federal false statements statute, 18 USC 1001, but tailored to health care benefit programs. Congress wanted a dedicated tool aimed at the kinds of lies that occur in medical billing, enrollment, and certification, rather than forcing prosecutors to rely solely on the general statute.

The statute covers two kinds of conduct. The first is falsifying, concealing, or covering up a material fact by any trick, scheme, or device. The second is making — or using — a materially false, fictitious, or fraudulent statement, representation, writing, or document. Both must occur in a matter involving a health care benefit program and in connection with the delivery of, or payment for, health care benefits, items, or services. As with the fraud statute, “health care benefit program” is defined broadly in 18 USC 24(b) to include both public programs like Medicare and Medicaid and private insurers — so the statute is not limited to government programs.

One feature worth understanding is how the statute reaches both affirmative lies and silence. A false statement on a claim form is the obvious case, but the statute also reaches the active concealment of a fact the provider had a duty to disclose. That breadth is why false statement counts attach to so many different kinds of health care cases — from enrollment applications to certifications of medical necessity to the records that back up a bill.

Elements the Government Must Prove

To convict under 18 USC 1035, the government must prove the following beyond a reasonable doubt. Each is a potential point of challenge for the defense.

1. A False Statement or Concealment

The defendant must have either falsified or concealed a material fact, or made or used a false statement, document, or writing. The defense can dispute whether any statement was actually false — statements that are literally true, or merely misleading, may fall outside the statute — or whether an omission amounted to unlawful concealment rather than a permissible interpretation, an oversight, or the absence of any duty to disclose.

2. Materiality

The false statement or concealment must be material — meaning it had a natural tendency to influence, or was capable of influencing, the decisions of a health care benefit program. A statement that could not have affected any payment or eligibility decision is not material, which makes this a frequent and important battleground. Even a false statement, if it was incapable of mattering to the program’s decision, may not support a conviction.

3. Knowing and Willful Conduct

The defendant must have acted knowingly and willfully. Honest errors, misunderstandings of complex billing rules, and good-faith reliance on staff or billing companies do not meet this standard. As with the fraud statute, intent is often the central dispute, and demonstrating that a statement reflected a genuine belief in its accuracy can defeat the charge.

4. Connection to a Health Care Benefit Program

The conduct must occur in a matter involving a health care benefit program and be connected to the delivery of or payment for health care benefits, items, or services. The defense can test whether the required connection actually exists, particularly where the statement related to something outside the program’s payment or coverage decisions.

Penalties Under 18 USC 1035

The statute carries a single, straightforward penalty tier — but its real significance lies in how it stacks with other charges.

While 5 years is lower than the 10-year maximum under the main fraud statute, false statement counts rarely stand alone, and that is the key to understanding their role. Each materially false statement can be charged as a separate count, so a handful of false documents can become a handful of counts. They are usually charged together with fraud, conspiracy, and sometimes False Claims Act exposure — so the total potential punishment in a case that includes 1035 counts is typically far greater than this single statute suggests. Prosecutors also value these counts because a false statement can be easier to prove than a sprawling fraud scheme, giving the government a fallback even if the broader theory falters.

Related Federal Statutes

• 18 USC 1347 (health care fraud) — the lead charge that false statement counts most often accompany.
• 18 USC 1349 (conspiracy and attempt) — used to charge agreements to make false statements as part of a scheme.
• 31 USC 3729 (False Claims Act) — the civil counterpart where false statements underlie false claims.
• 18 USC 1028A (aggravated identity theft) — sometimes added where patient identities are misused in false submissions.

How 18 USC 1035 Charges Are Defended

Because the statute requires both materiality and willful intent, defenses often focus on one or both. On materiality, the defense can show that the statement could not have influenced any program decision — that it was peripheral, duplicative of information the program already had, or irrelevant to payment. On intent, demonstrating good faith is central: that the defendant believed the information was accurate, reasonably relied on billing staff or coders, or made an honest error in a genuinely confusing area.

Other defenses establish that a statement was literally true, even if the government considers it misleading, or that an alleged omission was not a knowing concealment because there was no duty to disclose or no intent to hide anything. Because 1035 counts so often ride alongside a larger fraud case, the defense also has to be coordinated with the overall strategy — a concession that helps on one count can hurt on another. For a practical look at how these issues arise in everyday billing disputes, see our discussion of billing for services not rendered. As always, the right strategy depends on the specific statements at issue and the surrounding evidence.

Charged Under 18 USC 1035? Contact Us

A health care false statement charge is often a window into a larger federal investigation — which is exactly why it should be taken seriously from the start, even when the individual counts seem minor. KN Law Firm, APLC defends these cases in the U.S. District Court for the Central District of California and before the Ninth Circuit. Call (888) 950-0011 for a free, confidential consultation with attorney Chris Nalchadjian, available 24/7 in English and Spanish.