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What Is Medicaid Fraud?

Medicare and Medicaid are national medical health insurance programs that provide healthcare coverage. Medicare covers many of the healthcare expenses of people who are age 65 or older, people with a disability, or renal disease. Medicaid provides health care costs to people with low incomes. In most states, adults and dependent children are qualified to receive Medicaid with incomes up to 138% of the federal poverty line.

Medicaid and Medicare are subject to waste, abuse, and fraud. When fraud is involved, it can lead to criminal charges. Medicaid fraud involves making false representations or statements in order to obtain some benefit or payment that would not otherwise be provided. Fraud generally involves misrepresenting facts or concealing material facts. Medicare abuse usually involves practices that result in unnecessary cost or expense, and can also be the basis for criminal penalties.

What Are Some Examples of Medicaid Fraud?

Healthcare in the United States can be expensive and complicated. Billing government care providers, like Medicaid, requires following standard protocols. However, because of the size and scope of Medicaid, it can be subject to fraud or abuse. Common examples of Medicaid fraud may include:

• Billing for services that are never performed
• Billing for medical equipment that is not medically necessary
• Unlawfully paying for patient referrals or provider kickbacks
• Changing for a more expensive service than what was provided
• Unbundling a combined medical procedure to charge as multiple procedures
• Double billing or duplicate claims

Who Investigates Medicaid Fraud?

Medicaid is operated by a combination of federal and state agencies. Suspected Medicaid fraud can be investigated by multiple agencies or law enforcement agencies, including:

• State health department fraud investigators
• Office of Inspector General (OIG)
• Centers for Medicare & Medicaid Services (CMS)
• Internal Revenue Service (IRS)
• Federal Bureau of Investigation (FBI)
• Medicaid Fraud Control Unit

Financial fraud is often flagged by computer analysis that reviews health care records submitted to Medicaid. The CMS Fraud Prevention System (FPS) can look for suspicious activity or suspected patterns of fraud. After identifying suspicious activity, an investigation will further look into the health care providers involved to determine if there is evidence of provider fraud, including site visits, talking to patients, and reviewing the provider’s medical and billing records.

Can You Go To Jail for Medicaid Fraud?

Medicaid fraud can involve criminal and civil penalties. Health care fraud involving federal government healthcare agencies or programs is a felony offense. Under federal law, the penalties for federal health care fraud can include up to 10 years in federal prison time. If the fraud resulted in serious bodily harm to a patient, the penalties could increase to 20 years imprisonment. Felony convictions can harm your future job opportunities.

Healthcare providers are also prohibited from paying or accepting kickbacks for health care services. Violation of the Anti-Kickback Statute can result in up to 5 years in jail, thousands of dollars in fines, and Medicaid exclusion.

Unlawful self-referral involves a doctor referring a patient to medical services where the doctor has a financial interest. Violation of the Stark Law against physician self-referral can result in fines, restitution, punitive damages, and make the doctor ineligible for Medicare and Medicaid programs in the future.

What Happens If Someone Reports Me for Medicaid Fraud in Ohio?

If patients suspect their doctor has been improperly billing Medicaid for care, they may have an interest in reporting the doctor. Other doctors, health care workers, or family members may also report suspected Medicaid fraud. Under the False Claims Act (FCA), whistleblowers can recover up to 30% of the civil penalties recovered for fraud against the government.

What if You Are Accused of Medicaid Fraud?

If you are facing fraud allegations it does not necessarily mean you will be found guilty of any crime. You have legal defenses and constitutional protections to challenge the criminal charges in court with the right to legal counsel. There may be several viable defenses to a fraud charge, including improper billing caused by clerical errors or computer problems.

How Health Care Fraud Defense Lawyers Can Help

A federal fraud lawyer can help as soon as you learn about a fraud investigation. Legal representation can protect you from saying the wrong thing during a fraud interview. An experienced attorney can also inform you of your legal rights and the potential consequences of a plea agreement. A fraud attorney can also help negotiate favorable settlements to get the best possible resolution and avoid jail time or other severe penalties.