Medicare fraud involves fraudulent activity committed by a healthcare provider or organization that participates in the Medicare program. Medicare is a federal health insurance program for people aged 65 and older, as well as some younger individuals with disabilities.
Similarly, medicaid fraud refers to any deliberate and intentional act committed by a healthcare provider or organization to defraud the Medicaid program. Medicaid is a government-funded health insurance program for low-income individuals and families, and providers who participate in the program are expected to adhere to strict regulations and billing requirements.
Medicare and Medicaid fraud occurs when individuals or organizations knowingly or intentionally submit false or misleading claims or other information in order to receive reimbursement for services that were not provided, were medically unnecessary, or were billed at an inflated rate. This can take many forms, including billing for services or items that were never provided, altering medical records to support false claims, or offering kickbacks or other incentives to individuals in exchange for referrals or services.
In addition to deliberate fraud, there are also a number of other practices that can result in Medicare or Medicaid overpayments, such as coding errors, billing mistakes, and improper documentation. While these practices may not necessarily be fraudulent in nature, they can still result in losses for the government and may still be subject to penalties and fines.
Overall, Medicare and Medicaid fraud can occur at any stage of the healthcare delivery process, from provider billing and claims submission to patient enrollment and eligibility verification. In order to combat fraud and abuse, the government has established a number of anti-fraud measures, including investigative agencies, audit and review processes, and whistleblower programs. Healthcare providers and individuals should be aware of the risks of Medicare and Medicaid fraud and take steps to ensure compliance with relevant laws and regulations.
Examples of Medicare or Medicaid fraud can include:
Billing for services not actually provided: Providers may bill Medicaid for services that were not actually provided to patients. This can involve submitting claims for procedures or treatments that never occurred or billing for more services than were actually provided.
Double-billing: Providers may bill Medicaid and a private insurer for the same service, resulting in the provider being paid twice for the same service.
Billing for unnecessary services: Providers may bill Medicaid for unnecessary services, such as diagnostic tests or treatments that are not medically necessary, in order to increase their reimbursement.
False documentation: Providers may falsify documentation, such as medical records or billing statements, in order to support fraudulent claims for payment.
Kickbacks: Providers may receive kickbacks or other incentives for referring patients to other providers or for prescribing certain medications or treatments.
The law prohibits submitting claims for payment to Medicare or Medicaid that you know, or should know, are false or fraudulent. Medicare or Medicaid fraud could result in civil liability and/or a criminal conviction.
A violation under the civil False Claims Act could result in fines up to three times the loss to the government, plus $11,000 per each claim.
Civil liability may result even without proof of specific intent to defraud. This means that if a person lacked actual knowledge of a false claim, yet acted in deliberate ignorance or reckless disregard of the truth or falsity of information submitted, he or she may be held responsible. Examples of False Claims Act violations include upcoding, billing for services that were unnecessary or never rendered, or billing for services performed by an excluded individual.
The civil False Claims Act also allows for “whistleblowers” to file lawsuits and receive a share of the government’s monetary recovery. A whistleblower does not have to be associated with the company engaged in the alleged fraud. Examples of whistleblowers include patients or their family members, customers, co-workers, contractors, and competitors.
Individuals convicted under the criminal False Claims Act are subject to imprisonment for up to 5 years, and fines. A conviction also may result in future exclusion from Federal health care programs.
In many cases, multiple government offices collaborate to investigate fraud allegations and determine how to proceed. Have you been contacted by a government agency alleging misconduct? If so, contact us today to schedule a consultation and to learn how we can help.
If you are concerned about Medicare or Medicaid fraud, call us today to see how we can help. The call is free and confidential. We only take on clients who we believe we can help.
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