Medicare Fraud and Abuse

Posted by & filed under Crimes Defined, Federal Crimes, White Collar Crime.

 

Medicare Fraud and Abuse New Orleans Attorney

Medicare fraud is typically characterized by:

  • Knowingly submitting false statements or making misrepresentations of fact in order to obtain a federal health care payment for which no entitlement would otherwise exist;
  • Billing for services not rendered or supplies not furnished, including falsifying records.
  • Knowingly billing for services at a level of complexity higher than the service actually provided.
  • Knowingly soliciting, paying, and/or accepting remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs; or
  • Making prohibited referrals for certain designated health services.

One does not have to hold a professional license to be convicted of Medicare fraud — anyone can be found guilty. Defendants can range from those involved in solo ventures to broad-based operations by an institution or group.

 

Penalties

A Medicare Fraud conviction exposes individuals to potential criminal and civil penalties, including imprisonment and fines. Providers and health care organizations that are convicted of health care fraud risk exclusion from participation in Federal health care programs and the loss of their professional licenses.

 

Prison. Medicare Fraud is a serious offense, and can lead to lengthy prison sentences. Making a false claim or false statement in relation to a Medicare claim can result in a 5-year prison sentence per offense. Anyone convicted of Medicare care fraud also faces significant fines. For example, an individual making a false statement in a Medicare claim faces a fine of up to $250,000 per offense, while organizations which make false claims face up to $500,000 per offense. Organizations that engage in ongoing schemes which involve multiple counts of health care fraud violations can face millions, or even billions of dollars in fines.

 
Restitution. As part of a criminal Medicare fraud sentence, the judge can order defendants to pay back the amount of money they improperly obtained as a result of their fraudulent acts. For example, a doctor who improperly billed an insurance company for tests not performed, and who received payment for these tests, can be ordered to pay this money back to the insurance company. Restitution is in addition to a fine, which is paid to the government.

 
Probation. A person convicted of a Medicare fraud crime can also face a potential probation sentence. Probation limits a person’s freedom and is an alternative to sending the someone to serve to a prison term. Probation usually lasts as least 12 months, though sentences over one year are more common. Those on probation must comply with specific conditions, such as regularly meeting with a probation officer, maintaining employment, not associating with known felons, and not committing more crimes.

 

What Is Medicare Abuse?

Medicare abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and priced fairly.

Examples of Medicare abuse include:

  • Billing for services that were not medically necessary;
  • Charging excessively for services or supplies; and
  • Misusing codes on a claim, such as upcoding or unbundling codes.

Medicare abuse can also expose providers to criminal and civil liability.

 

Medicare Fraud and Abuse Laws

Federal laws governing Medicare fraud and abuse include the:

  • False Claims Act (FCA);
  • Anti-Kickback Statute (AKS);
  • Physician Self-Referral Law (Stark Law);
  • Social Security Act; and
  • United States Criminal Code.

These bodies of law specify the criminal and/or civil penalties the government can impose upon individuals or entities that commit fraud and abuse in the Medicare Program, including Medicare Parts C and D, as well as the Medicaid Program. Violations of these laws may result in nonpayment of claims, Civil Monetary Penalties (CMPs), exclusion from participation in Federal health care programs, and criminal and civil liability. Liability can exist without proof of actual knowledge or a specific intent to violate the law.

Please stay tuned. I will be briefly summarizing each law regarding Medicare Fraud in future blog posts.

 

Legal Representation

If you are being investigated for Medicare Fraud in Louisiana, contact New Orleans federal crimes defense attorney Elizabeth B. Carpenter for a consultation. She has the experience that you need for a strong defense.

 

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