Criminal Law - Federal

Medicare Fraud

Medicare is the federal government insurance program for older people and people with disabilities. When doctors, patients, or others use the federal program to commit health care fraud, they can face federal Medicare fraud charges. Federal criminal charges should be taken seriously. If you have questions about a Medicare fraud investigation, contact a federal criminal defense attorney for legal advice.

What Is Medicare Fraud?

Medicare fraud involves using the health care system to defraud the government to get fraudulent reimbursements for medical services or other benefits.

Part of the Centers for Medicare & Medicaid Services, the Medicare program is a federally funded government health care insurance program that provides medical insurance benefits to individuals who are 65 years of age or older. You may also qualify for Medicare even if you are under 65 if you have a certain disability or qualifying medical condition.

Who Can Be Charged with Medicare Fraud?

Anyone, including a patient, health care professional, or other health care provider can be charged with Medicare fraud. If a doctor, pharmacist, or other business organization or health care provider fraudulently gets a Medicare reimbursement, they could be investigated for Medicare fraud.

For a fraud conviction, the prosecutor has to show that you acted with the intent to defraud. Innocent billing mistakes that are not part of a pattern are generally not considered fraud. However, you may still have to reimburse the government for any benefits you received.

If you or your organization is charged with health care fraud or for filing fraudulent claims, you could face serious criminal and civil penalties. Doctors convicted of fraud can also lose their ability to participate in Medicare and Medicaid programs in the future.

What Are the Types of Medicare Fraud?

Some examples of Medicare fraud can include:

  • Upcoding: Charging for a more complicated and expensive medical procedure than the medical service the doctor provided
  • Kickbacks: When a provider or doctor recommends a prescription drug or medical device from a drug company or device maker in exchange for money
  • Fraudulent billing: Billing Medicare for health care services that were never provided
  • Medical identity theft: Using someone’s Social Security number, Medicare number, or Medicare card to submit a false Medicare insurance claim

What Federal Agencies Investigate Medicare Fraud?

The federal government is always on the lookout for health care fraud. There are several federal agencies that investigate Medicare fraud, including:

  • Department of Justice
  • U.S. Department of Health and Human Services
  • Centers for Medicare & Medicaid Services
  • FBI

Many states have medical strike force teams to help investigate and analyze data to help crack down on health care fraud schemes. Senior Medicare Patrols (SMPs) are federally funded grant projects that were also created to help seniors understand how to prevent and avoid health care fraud.

What Are the Criminal Penalties for Medicare Fraud?

The two statutes most commonly used in Medicare and Medicaid fraud criminal prosecutions are the Health Care Fraud Statute and the Anti-Kickback Statute. Other laws that may be used to address fraud include the False Claims Act, which can include civil penalties of up to three times the amount of the false claim.

Under the criminal Health Care Fraud statute, you could face felony penalties of up to 10 years in prison. The penalties for health care fraud that causes serious bodily injury can include imprisonment for up to 20 years. If health care insurance fraud resulted in death, penalties can include life in prison.

If you are a doctor or health care provider who committed Medicare fraud, you can face serious civil penalties, including losing your medical license. Civil penalties can include restitution or having to pay back the false reimbursement. You could also be prevented from being able to take part in a government-benefit insurance program in the future.

If you are facing charges, you should work with your attorney to determine the best way to defend yourself. Common defense strategies to Medicare fraud charges can include:

  • Lack of evidence
  • Lack of intent (you made an honest mistake)
  • Your health care provider took efforts to avoid fraud

If you are facing criminal or civil penalties for Medicare fraud, take action to protect your license or business today. Contact a Medicare fraud attorney for legal advice as soon as possible.

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