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What is Medicare Fraud?

Medicare is a federal health insurance program that provides medical benefits including hospital care, nursing home care, certain doctor services, and may help cover prescription costs. There are different monthly plans that have different benefits and premiums. Medicare is available for people who are:

  • Age 65 or older
  • Certain people with disabilities
  • People with End-Stage Renal Disease (ESRD)

Medicare fraud involves making a fraudulent claim in an attempt to collect Medicare health care benefits or reimbursements. Such fraud can involve anyone involved in health care for Medicare-eligible individuals, including doctors, medical professionals, home health services, and people making referrals for kickbacks.

Medicare fraud is a criminal offense. Like other types of insurance fraud or health care fraud, a conviction for Medicare fraud can result in jail time, heavy fines, and restitution. If a doctor or healthcare provider is convicted of Medicare fraud, they may be prohibited from seeking reimbursement from Medicare insurance care in the future.

What Qualifies as Medicare Fraud?

Medicare fraud can involve many different forms. Generally, Medicare fraud involves a doctor or health care worker seeking unlawful compensation from Medicare insurance. Some common examples of Medicare fraud include:

  • Billing for services that were never provided
  • Providing or receiving unlawful kickbacks for referrals
  • Unbundling and charging separately for services regularly performed together
  • Double billing or duplicate billing
  • Billing for medically unnecessary services and tests
  • Up-coding or billing at a higher rate
  • Misrepresentation of the type of service provided

Who Investigates Medicare Fraud Cases?

Medicare investigations generally fall under the jurisdiction of the Department of Health and Human Services (HHS), Office of Inspector General (OIG). The OIG handles whistleblower reports and complaints of fraud in the use of HHS programs, including Medicare and Medicaid. After the OIG discovers possible fraud, they may take a number of enforcement actions, including criminal charges, civil charges, or administrative actions. The OIG and Medicare Fraud Strike Force Teams may work with a number of other law enforcement and investigative agencies, including:

  • Federal Bureau of Investigation (FBI)
  • Department of Justice
  • Drug Enforcement Administration (DEA)
  • Internal Revenue Service (IRS)
  • Local law enforcement

Is Medicare Fraud a Felony?

Health care fraud involving Medicare is a federal felony. It is a crime for whoever knowingly and willfully executes a scheme to defraud any healthcare benefit program. The penalties for a federal government fraud conviction include up to 20 years in federal prison.

There are a number of federal laws that govern Medicare fraud, including:

  • False Claims Act
  • Anti-Kickback Statute
  • Criminal Health Care Fraud Statute
  • Physician Self-Referral Law

Under the Anti-Kickback Statute (AKS), it is a crime to knowingly and willfully offer, pay, solicit, or receive any compensation to induce or reward patient referrals. Criminal penalties for a kickback conviction can include fines, imprisonment, and exclusion from participating in Medicare.

The Federal Civil False Claims Act (FCA) also provides civil liability for Medicare benign overcharged or defrauded. Civil penalties provide for up to three times the amount of damages.

Do You Need a Medicare Fraud Lawyer?

A Medicare fraud attorney can provide legal representation in a criminal, civil, or administrative action. Medicare fraud is a criminal offense, with severe penalties, including jail time, fines, and a permanent criminal record. In addition, the defendant may face financial penalties and triple damages if found guilty of government fraud offenses.

A criminal defense lawyer can evaluate your case, identify strategic defense options, and defend you in court to avoid a criminal record. An experienced attorney can also negotiate with investigators to reduce the criminal charges. Defense strategies include:

  • Fraudulent billing was the result of a computer error
  • Fraudulent activity was caused by human error
  • Coding errors were committed by mistake
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