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Medicaid Fraud

Medicaid fraud varies from state to state and includes a variety of actions that can lead to the investigation and eventual prosecution of the crime. You may find yourself in the midst of a Medicaid fraud case and not even realize it. If you suspect something amiss in your claim for Medicaid, or your Medicaid records, you may wish to contact a Medicaid fraud attorney who will help evaluate your situation.

What Is Medicaid Fraud?

Medicaid fraud occurs when an individual or entity participates in an intentional defrauding of Medicaid. Common participants include health care practitioners such as doctors, nurses and administrators, as well as individual patients or people misrepresenting themselves as eligible patients.

Common examples of Medicaid fraud, include but are not limited to:

  • Ordering rounds of redundant or unnecessary tests or specialist referrals in a cycle (ping-ponging)
  • Billing sessions, appointments, operations or prescriptions that never actually occurred (phantom billing)
  • Filing illegitimate reimbursement claims beyond the coverage that is lawfully offered
  • Abuse or neglect of individuals entitled to proper, professional care within the Medicaid program

What Happens in a Medicaid Fraud investigation?

Under the jurisdiction of the Department of Health and Human Services, Medicaid Fraud Control Units (MFCUs) investigate claims of fraud within the Medicaid system. The stated goal of MFCUs is not only to detect willful fraud but also to protect vulnerable individuals who may be placed within the system and are subjected to abuse or neglect.

The MFCU, in general, works with the state’s attorney general. Reports of fraudulent behavior, or patterns of suspicious behavior, are identified by investigators attached to the MFCU and are then referred to relevant prosecutors working with the fraud control unit. Each MFCU must employ professionals with expertise in audits, investigating and prosecuting to handle any fraudulent behavior in the Medicaid program.

Is Medicaid Fraud a Federal Offense?

Medicaid fraud is a serious federal offense. If you are convicted of Medicaid fraud, you could face up to life imprisonment if your fraudulent behavior results in the death of another, up to 20 years imprisonment if the fraud causes serious bodily harm to a victim or up to 10 years behind bars if the offense was limited to financial fraud only.

Health care providers who forward false claims can face punishments ranging from up to five years imprisonment in addition to fines of up to $250,000 for individuals or $500,000 for corporations. Meanwhile, the penalty for making false statements in relation to health care can be up to five years imprisonment and a potential fine of up to $100,000.

Medicaid Fraud Penalties

Most states break down the penalty for Medicaid fraud into several categories of felony offenses. Florida, for example, punishes Medicaid fraud amounting to over $100,000 in costs as a first-degree felony, resulting in a potential prison sentence of 30 years if you are convicted in addition to steep fines.

More broadly, the penalty for Medicaid fraud largely depends on the value of the services fraudulently claimed, billed or forwarded. Most states respond to lesser felony charges with punishments of up to five years imprisonment, with more serious cases having a maximum sentence of 20 to 30 years or life incarceration.

How to Prove Medicaid Fraud

Medicaid fraud charges are based on a thorough examination of the physical evidence such as records of appointments, billing sheets and receipts, records of surgeries or prescriptions, as well as interviews with all relevant parties.

Investigators and auditors attached to an MFCU are generally highly trained professionals who are skilled in unearthing abuse of the Medicaid system. Investigators compare your statements with the body of evidence they have to work with, and by highlighting suspicious discrepancies, can build a case for the prosecution.

Medicaid Fraud Defense Strategies

As with many criminal cases involving fraud, there are several common strategies deployed by defense attorneys.

Lack of intent, or having “made a mistake” regarding the paperwork, may hold up in court if the evidence allows for such an argument. Lack of intent may not be a viable defense in certain instances, however.

Arguing that the evidence provided by the prosecution is tainted by having been acquired unlawfully, or via duress or entrapment, may also be a good legal strategy particularly if auditors or investigators were misleading or aggressive in their pursuit of the case.

What it Means To Be Accused of Medicaid Fraud

Medicaid fraud and associated punishments for breaking these laws vary based on the state in which the crime was committed and the details of the case. A bar-certified attorney familiar with the laws in your jurisdiction will present the best counsel on a potential Medicaid fraud case. When it comes to Medicaid fraud, you may be accused of:

  • False Cost Reporting
  • Personal or professional kickbacks
  • A variety of unethical billing practices
  • Generic drug substitutions
  • False identity and falsifying credentials

How a Medicaid Fraud Attorney Can Help You

If you have been accused of Medicaid fraud, it is imperative that you seek legal counsel immediately. Medicaid fraud has both state and federal implications and only an experienced attorney will be able to inform you of your rights and prepare the best defense for your case. Take advantage of your rights as a citizen and find the best legal representation to support you in court. Don’t take your chances with the law. If you are involved in a Medicaid fraud case, contact a Medicaid fraud attorney who can help you today.

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