What Is Medicaid Fraud?

Many people with lower incomes depend on Medicaid for health care for themselves and their families. Like other government and insurance programs, dealing with Medicaid can be frustrating and complicated for both patients and health care providers. In some cases, a simple mistake on a form can lead to an investigation for potential fraud.

Accusations of defrauding the federal government should be taken seriously. If you are under investigation for Medicaid fraud or health care fraud, talk to a federal criminal defense lawyer for legal advice.

What Is Medicaid Fraud?

Medicaid is a federal government health insurance program for low-income Americans. According to the federal government, there were more than 93 million individuals enrolled in the Medicaid program in 2023. Medicaid reimburses health care providers, facilities, and pharmacies for providing care to enrollees.

Some people try to take advantage of the federal government health care benefit by misrepresenting or concealing information to qualify. Medical providers commit fraud when they engage in false billing for services they didn’t provide. This includes providing unlawful health care referrals for Medicaid patients.

Who Can Be Accused of Medicaid Fraud?

Medicaid recipients can be accused of Medicaid or Medicare fraud involving:

• Identity theft, or using someone else’s medical identity or contact information
• Presenting false information to meet eligibility criteria
• Failing to report assets, income, employment, or marriage status

Some of the ways doctors or other health care providers can commit Medicaid fraud or charge for unnecessary services can include:

• Upcoding, or charging for a more expensive procedure than was provided
• Accepting kickbacks, or financial perks from a pharmaceutical company or other medical care practice for a prescription or referral
• Billing for services that were never provided

Who Investigates Medicaid Fraud?

According to the U.S. Department of Health and Human Services (HHS), there were 1,327 convictions for Medicaid fraud in 2022. Medicaid fraud is investigated by Medicaid fraud control units (MFCUS), an arm of the Department of Justice. A conviction for Medicaid provider fraud can limit your future eligibility for health care benefits along with both criminal and civil penalties.

What Are the Penalties for Medicaid Fraud?

Criminal and civil penalties for Medicaid fraud depend on whether you are a patient, health care provider, nursing home, or medical professional. Civil penalties under the False Claims Act for suspected fraud include:

• Fines of more than $13,000 to over $27,000, adjusted annually for inflation
• Restitution in the amount of medical services defrauded
• Exclusion from Medicaid and other health care benefit programs
• Loss of a health care provider license

Criminal penalties under the False Claims Act include:

• Up to five years in prison
• Restitution for the amount of overpayment
• Fines of up to $250,000 for individuals and $500,000 for businesses

What Are Legal Defenses to Medicaid Fraud Charges?

If you are suspected of Medicaid fraud, a lawyer will evaluate your case and identify the best defense strategy. Common defenses against Medicaid fraud can include:

• Mistake
• Lack of intent
• False allegations
• Lack of evidence
• Lack of proof that the fraud was material

Facing a law enforcement investigation for Medicaid fraud charges can be intimidating. Contact an experienced Medicaid fraud attorney before deciding the next steps to take in defending yourself against Medicaid fraud charges. An experienced lawyer can make the difference in building the strongest possible defense and getting the best possible outcome.