Medicare and Medicaid Fraud by Health Care Providers

Of the types of health care fraud, Medicare and Medicaid fraud are among the most common forms of misconduct prosecuted under of the federal False Claims Act (FCA). The False Claims Act was enacted in 1863 by Congress and is also known as the “Lincoln Law.” It’s a law that protects the government against false claims for payment from government funding programs.

The False Claims Act also protects whistleblowers and even provides them with an incentive to disclose alleged fraud by payment of a percentage of the damages that prosecutors recover from the guilty parties. FCA cases may involve significant sums because the damages may to be tripled. Since the law was amended in 1986, the federal government has recovered $35 billion in fraudulent payments.

The Many Forms of Medicare And Medicaid Fraud

Medicare and Medicaid fraud takes many forms. Some of those forms are:

  • Physicians, pharmacies, and wholesalers taking kickbacks after initiating a device or drug purchase
  • Inflating drug prices to justify higher reimbursement from Medicare or Medicaid.
  • Billing Medicare or Medicaid for defective test kits
  • Selling defective medical devices and submitting a claim for payment
  • Failure to report the true best price for a drug in order to reduce the rebates the government program can claim
  • Billing for services not provided
  • Double billing, unbundling, or upcoding
  • Inadequate medical documentation
  • Billing by unlicensed and unqualified providers
  • Physician self-referrals
  • Stark Law Violations – payment by Medicare or Medicated for health services that are furnished in violation of the Stark Law. Stark law is “strict liability” law.
  • Even relatively insignificant cases involving defrauding the Medicare or Medicaid system justifies an accusation of fraud as it pertains to the False Claims Act.

    The False Claims Act In Depth

    The False Claims Act provides that a person is guilty of Medicare or Medicaid fraud if they knowingly present a false claim or cause the presentation of a fraudulent claim for payment. The penalty for violation of the FCA can be as high as $250,000 and up to five years in prison. The exact fine is determined by the Federal Civil Penalties Inflation Adjustment Act of 1990. This monetary penalty is in addition to three times the amount of damages incurred to the government as a result of the health care provider’s actions.

    Obtaining Legal representation Upon Notice of An Audit

    To determine if fraudulent actions took place, the government will perform an audit. When facing federal or Maine state charges involving Medicare or Medicaid fraud, it’s important to obtain legal representation as soon as possible so the facts can be gathered and a solid defense prepared. The monetary fines are serious and, depending on the nature of the offense, prison time is also a possibility, so this is a charge that requires the assistance of a competent, experienced attorney such as the Law Office of Richard S. Berne.