How Do Examinations Under Oath Signal a Healthcare Fraud Investigation?

What is an Examination Under Oath

An Examination Under Oath (EUO) under California Insurance Code § 2071.1 is a formal, sworn proceeding in which an insurance company questions a policyholder (the insured) about the facts, circumstances, and details of an insurance claim. It is usually set when the insurance company is suspecting that the claim is fraudulent. The examination is typically conducted by an attorney or representative for the insurer, with a court reporter present to transcribe the testimony under oath (similar to a deposition but occurring during the claims investigation process, before any lawsuit). It is important to distinguish between a hostile examination where fraud is the true focus vs. an information gathering process where you insurance company is attempting to see whether you or the other side (in a car accident claim for example) is telling the truth about what happened. If you refuse an examination under oath you will risk losing insurance coverage. On the other hand, these examinations are sometimes used by the insurance company as ammunition to have the insured (you) charged criminally with fraud. Be careful! Context and Purpose California Insurance Code § 2071 (the standard fire insurance policy provisions, which many property policies incorporate) requires the insured to "submit to examinations under oath" as a condition of the policy, "as often as may reasonably be required" and "subject to the provisions of Section 2071.1." The EUO helps the insurer gather information that is often uniquely known to the insured, such as:

Details of the loss or damage
Circumstances surrounding the claim
Documentation of the claim amount
Potential coverage issues
Fraud and abuse

This tool is not restricted to medical fraud cases. This blog explains a provider EUO but first, it is useful to understand the more common EUO where an insured person is refused payment until an EUO is completed.

First remember that there are rarely innocent EUO. In 99.9% of the cases the insurance company suspects fraud or has serious questions as to whether or not the claim is covered by the policy. Once in a long while an insured may be subjected to an EUO because their version of an accident differs from the other party and their own insurance company wants to be certain as to what the facts are so they can make an informed decision as to whether you or the other person is at fault.

In a non-healthcare context here is an example of how an EUO was used by a fire insurance company.

We had a fire case once where the OE focused on why the owner's dogs were out of the house when the fire started. The insurance company anticipated fraud knowing that the owner was unwilling to sacrifice the lives of his dogs when he set the fire! It is not intended for harassment or unrelated purposes. Insurers commonly request an EUO in property damage claims (e.g., fire, theft, or other covered losses), especially if there are questions about the claim's validity, the extent of loss, or suspected issues like misrepresentation.

What are the Rights of an Insured?

Whether you are a healthcare provider or insured under a policy certain meaningful protections apply to these examinations.

Key Rights of the Insured are under Insurance Code § 2071.1. Section 2071.1 (enacted in 2001) acts as a "Bill of Rights" for insureds during an EUO. It applies to examinations under the standard fire policy (or similar provisions in property policies originated or renewed on or after January 1, 2002). Among the rights are:

Notice requirement: The insurer must notify the insured of its intent to conduct the EUO and include a full copy of § 2071.1 with the notice.

Scope limitation: The insurer may only ask about information that is relevant and reasonably necessary to process or investigate the claim. Questions must stay within proper bounds (the insured can object to improper questions, similar to objections allowed in a deposition under state or federal law).

Reasonable conditions: The EUO must occur on reasonable notice, at a reasonably convenient place, and for a reasonable length of time.

Representation and recording: The insured may be represented by counsel and may record the entire proceeding (including audio or video). But beware that this recording may be discoverable in a civil lawsuit. So in other words a third party who is not involved wtih your insurance company but is suing you for a car accident (as an example) - may demand that recording!

Transcript and recording access: Upon request (and free of charge), the insurer must provide the insured with a copy of the transcript and any audio/video recording that exists.

Other protections: The insured can assert privileges (e.g., certain tax returns may be privileged but might still be relevant in some cases), and the process must comply with the overall duty of good faith and fair dealing.

The Application of Examinations Under Oath to Doctors Who Provide Medical Treatment

I am the Treating Doctor - Can I Be Required to Sit for an Examination Under Oath?

The short answer is yes. A doctor who has an in-network provider contract with a healthcare or health insurance company can absolutely be subjected to an Examination Under Oath (EUO).

However, the mechanism and rules driving a provider EUO are fundamentally different from the standard EUO provisions seen in standard consumer property or casualty policies. It comes down to contractual frameworks and the context of the underlying claims.

Here is a breakdown of how this happens, the triggers, and the unique dynamics involved.

1. The Power is in the Participating Provider Contract

When an individual policyholder faces an EUO, it is triggered by standard policy language (and often reinforced by state statutes, like California Insurance Code § 2071 for fire/property claims).

For a treating physician, the obligation does not stem from the patient's insurance policy, but rather from the Managed Care Contract or Participating Provider Agreement the doctor signed with the health plan.

Virtually all modern in-network provider agreements include expansive "Cooperation and Audit" or "Special Investigation" clauses.
These clauses contractually obligate the provider to submit to interviews, provide peer-review inputs, turn over administrative/financial records, and, if requested during a formal fraud or billing investigation, submit to sworn statements or examinations under oath.
The Penalty for Refusal: If a doctor refuses to cooperate with a contractually mandated EUO, the insurer can unilaterally withhold all pending claims payments, terminate the network contract for cause, or potentially use this refusal to report the physician to the state licensing board for a lack of cooperation along with the evidence that triggered the demand for the EUO in the first place.
There is no Fifth Amendment Right: The insurance company is not a government entity so you do not have a Fifth Amendment right to remain silent. Your refusal to cooperate can be used against you as evidence that you had a consciousness of guilt.

2. Common Triggers for a Provider EUO

Health insurance companies rarely invoke an EUO for simple, routine medical billing disputes. When an insurer brings in specialized outside counsel or fraud investigators to put a doctor under oath, it is typically driven by high-stakes compliance or fraud indicators:

Mallela-Type Corporate Status Investigations: Insurers frequently use EUOs to investigate whether a clinic is actually owned and controlled by a licensed medical professional, or if it is secretly a "pinstripe practice" split-funded or controlled by non-doctors or marketers in violation of corporate practice of medicine doctrines.
Upcoding and Bill Padding: If AI-driven predictive billing audits show a doctor is consistently billing an statistically anomalous number of high-level CPT codes (e.g., Level 5 E/M codes or complex unbundled surgeries) compared to peers, an EUO may be used to dissect specific charts line by line under penalty of perjury.
The Personal Injury / No-Fault / Med-Pay Context: Provider EUOs are incredibly common in states with robust No-Fault (Personal Injury Protection) systems or in third-party auto-liability Med-Pay claims. Insurers look for systemic pipelines between specific personal injury attorneys and diagnostic/chiropractic/medical clinics to uncover organized fraud rings.

3. How a Provider EUO Operates in Practice

A provider EUO is structurally identical to a standard deposition, but it occurs entirely within the investigative claim phase before any lawsuit is filed.

The Setup: It is conducted by an insurance defense attorney, recorded verbatim by a court reporter, and the physician is sworn in under penalty of perjury.
Document Production: The notice for a provider EUO is almost always accompanied by a massive demand for records. This goes far beyond the patient's immediate medical chart; insurers routinely demand the clinic's internal scheduling logs, billing software audit trails, payroll records for treating physical therapists or assistants, and corporate banking documents.
The High Stakes: Because the testimony is under oath, any material inconsistencies, admissions of improper billing, or evidence of pre-signed charts can be used by the insurer as immediate grounds to deny thousands of outstanding claims, initiate a civil recoupment action, or refer the matter to the state medical board or federal authorities for healthcare fraud.

4. Can the EUO Be Used Against a Doctor in a Lawsuit or Criminal Case?

There are certain legal arguments and evidentiary objections that may in certain cases bar the use of the EUO in a separate civil lawsuit or criminal prosecution. But the default answer is the opposite - "Yes" - an EUO can be used as evidence against a doctor in a civil lawsuit or healthcare fraud prosecution.

Bottom Line:

A EUO directed at healthcare provider is a very serious matter and in most cases indicates that the doctor (not the patient) is under scrutiny for fraud. You should never attend an EUO with first consulting with a criminal defense lawyer who has specialized expertise in medical law. An EUO demand tells you that an investigation is underway and the EUO is just the tip of the iceberg. You need immediate legal assistance.

Daniel Horowitz is both criminal defense law specialist and a highly respected physician / medical lawyer. Call for an initial consultation - (925) 283-1863,

Healthcare Fraud & Examinations Under Oath