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2415 E. Camelback Road, Suite 500, Phoenix, AZ 85016
2025 N. 3rd Street, Suite 157, Phoenix, AZ 85004
4500 S Lakeshore Dr, Suite 352, Tempe, AZ 85282
7322 E. Thomas Road, Scottsdale, AZ 85251
8585 East Hartford Drive, Suite 700, Scottsdale, AZ 85255
2150 E Highland Ave, Suite 212, Phoenix, AZ 85016
2325 E Camelback Rd, Suite 700, Phoenix, AZ 85016
714 N. 3rd St., Suite 4, Phoenix, AZ 85004
1850 North Central Avenue, Suite 1400, Phoenix, AZ 85004
1731 West Baseline Rd. Suite #101, Mesa, AZ 85202
2415 E Camelback Rd, Suite 700, Phoenix, AZ 85016
2425 East Camelback Road, Suite 900, Phoenix, AZ 85016
2231 E Camelback Rd, Suite 200, Phoenix, AZ 85016
7310 N 16th St, 330A, Phoenix, AZ 85020
PO Box 447, Tempe, AZ 85280
2375 East Camelback Road, Suite 600, Phoenix, AZ 85016
3200 N Central Ave, Suite 1600, Phoenix, AZ 85012
6121 North 3rd Ave, Phoenix, AZ 85013
80 E Rio Salado Pkwy, Suite 305, Tempe, AZ 85281
2800 N. Central Ave, Suite 860, Phoenix, AZ 85004
16165 N. 83rd Ave, Suite 200, Peoria, AZ 85382
3200 N Central Ave, Suite 2250, Phoenix, AZ 85012
1221 E Osborn Rd, Suite A-200, Phoenix, AZ 85014
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2930 E Camelback Rd, Suite 160, Phoenix, AZ 85016
Peoria Medicare Fraud Information
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What Constitutes Medicare Fraud?
Medicare is a national health insurance program, administered under the Centers for Medicare and Medicaid Services (CMS). Medicare covers many of the healthcare expenses of enrollees. Uncovered services and remaining costs may be covered by private insurance or other government benefit programs. To be eligible under Medicare, the individual has to meet one of the following requirements:
- Age 65 or older and a U.S. citizen, or LPR for 5 continuous years with a qualifying spouse or ex-spouse
- Under 65 with a disability and have been receiving SSDI or other disability benefits for a qualifying period of time
- People with End-Stage Renal Disease (ESRD) receiving continuing dialysis
Medicare fraud involves making false claims or fraudulent misrepresentations for Medicare health care benefit reimbursement. According to the Government Accountability Office, Medicare is vulnerable to fraud, with a low rate of Medicare claim audits. People accused of Medicare fraud can involve anyone involved in government healthcare benefit program, including:
- Doctors and medical providers
- Billing professionals
- Health care professionals
- Health care services companies
- Insurance companies
- Pharmaceutical companies
What Are Examples of Medicare Fraud?
Medicare fraud generally occurs between medical care providers and patients, vendors, or other doctors. There are several examples of medical billing fraud, anti-kickback violations, and financial gain through improper self-referral. Some common examples of Medicare fraud include:
- Billing for services that are not necessary
- Health care provider treatment for an undiagnosed condition
- Charging for an unnecessary expensive service
- Paying kickbacks for referrals
- Unbundling medical procedures
- Double billing or duplicate claims
- Up-coding
- Billing for medical services never provided
How is Medicare Fraud Determined?
There are several ways Medicare fraud can be identified. Suspected fraud can be reported by patients, healthcare providers, or even employees. Health care fraud cases can also be identified through computer analysis. CMS uses a Fraud Prevention System (FPS) to identify possible fraud. According to CMS, the FPS is a “state-of-the-art predictive analytics technology.”
The system assesses all Medicare fee-for-service claims to identify fraudulent claims and take administrative action. When patterns of inappropriate billing are identified, investigators conduct site visits, interview patients, and review medical records to identify fraud.
The Office of Inspector General (OIG) has a hotline for reporting potential fraud and Medicare abuse. Patients, co-workers, or employees may have an incentive for reporting fraudulent billing and may be eligible for whistleblower awards under some federal programs.
Is Medicare Fraud Civil or Criminal?
Medicare fraud charges can involve both civil and criminal laws and penalties. Federal health care fraud carries felony criminal charges. The penalties for a conviction of federal government fraud include up to 10 years in federal prison, or up to 20 if it resulted in serious bodily injury.
When a doctor refers a Medicare patient to another business or provider where the doctor has a financial interest, it may be a violation of the Physician Self-Referral Law, or the Stark Law. Civil penalties for illegal patient referrals include civil penalties, treble damages, and Medicare program exclusion.
The Anti-Kickback Statute is a criminal statute, with penalties including possible imprisonment for up to five years, fines, and exclusion from federal benefit programs.
The False Claims Act (FCA) provides for civil penalties where a doctor defrauds the federal government. The FCA also provides a reward system, and whistleblowers can recover up to 30% of the money recovered by the government.
Other penalties may include restitution, or paying back the victims of fraud. After a conviction for Medicare fraud, a doctor could also lose their medical license or be excluded from participating in Medicare or Medicaid. Medicare fraud may also involve other criminal violations, including:
- Identity theft
- Forgery
- Money laundering
- Wire fraud
- Insurance fraud
What if You Are Accused of Medicare Fraud?
Not all Medicare fraud criminal investigations involve criminal intent. There are a number of possible explanations or legal defenses when a doctor faces fraud allegations. In many cases, suspected fraud may be caused by simple mistakes or unclear rules, without any intention of fraud. A fraud attorney can review your case for a strategic defense, with possible defenses including:
- Accidentally putting in the wrong billing code
- Accidentally ordering extra diagnostic tests
- Billing employees did not have the proper training
- Patient claimed they did not already have a procedure or test
- Misspellings or unclear handwriting