Medicare Fraud

Medicare fraud is the collection of Medicare health reimbursement under false pretenses. There are numerous types of Medicare fraud, but all have the same primary purpose, which his to illegitimately collect money from the Medicare program.

Miami Medicare fraud defense lawyers at Jacobs Keeley know that with increasingly aggressive prosecution of these cases, defendants are in for a major fight. Our team is prepared to initiate a formidable defense. While an allegation of Medicare fraud alone can be extremely damaging to one’s reputation and livelihood, developing a solid defense strategy early on can help minimize the long-term effects – and possibly keep you out of prison.

Although the actual rate of Medicare fraud is difficult to determine (fraud, by its very nature, seeks concealment), educated estimates put the figure at somewhere between 8 and 10 percent (or about $60 billion annually) of program disbursements. Compare that to credit card fraud, which has a fraud rate of about 0.04 percent.

South Florida in particular is considered a central hub for Medicare fraud. A hotline established for reporting Medicare fraud locally was credited with resulting in more than 1,000 fraud investigations over the course of five years.

Particularly as health care costs have reached astronomical levels, Medicare fraud has become a key target for federal law enforcement agencies and prosecutors. It is almost always going to be tried at the federal level because it involves theft or fraud committed against a federal program.

Federal laws government Medicare fraud and abuse include:

  • False Claims Act
  • Anti-Kickback Statute
  • Physician Self-Referral Law
  • Social Security Act
  • United States Criminal Code (Criminal Health Care Fraud Statute)

These statutes effectively shape the criminal and/or civil penalties and remedies the government can seek against individuals and organizations that commit Medicare fraud and abuse.

Types of Medicare Fraud

Medicare fraud schemes can involve almost anyone, though high-profile prosecutions tend to focus on operations that were broad-based and perpetuated by an institution or group.

Some of the most commonly prosecuted types of Medicare fraud are:

  • Phantom billing, or billing for tests that were never performed.
  • Performing unnecessary or inappropriate procedures.
  • Charging for supplies or equipment that was never ordered.
  • Billing Medicare for new or expensive equipment, while providing the patient used or cheap equipment.
  • Certificate of Medical Necessity completed by an equipment or drug supplier, as opposed to a doctor.
  • Reflex testing, or automatically running tests whenever other criteria fall within a certain range, even when the test was not requested by a doctor.
  • Code jamming, or the insertion of fake diagnosis codes in order to obtain Medicare coverage
  • Submitting multiple bills to obtain higher reimbursement for services that should have been submitted in the same bill.
  • Double billing, or charging more than a single time for the same service.
  • Up-coding, or inflating bills by using codes that indicate the patient’s condition was more severe than un actuality.
  • Giving substandard care to nursing home patients while seeking reimbursement from Medicare.
  • Offering or accepting kickbacks.
  • Submission of improper cost reports.
Prosecution of Medicare Fraud

The federal Anti-Kickback statute makes it illegal to pay for or receive anything of value in exchange for referring patients covered by Medicare or other government health care program. Convictions under this law can result in a five-year prison term, a $25,000 fine and exclusion from federal health care programs.

The Physician Self-Referral (or Stark Law) bars doctors from referring Medicare patients for certain designated health services to an entity to which the doctor or an immediate family member has a financial relationship. The term “financial relationship” could mean anything from indirect investment to a direct compensation arrangement. Penalties can include denial of payment for services provided, an order to refund money received, fines of up to $15,000 for each claim, exclusion from the Medicare program and up to $100,000 for attempts to circumvent the statute.

The False Claims Act is supposed to protect the government from being overcharged or sold goods or services that are substandard. Civil penalties for violation of FCA in relation to Medicare fraud can range from between $5,500 to $11,000 per claim.

Finally, the Criminal Health Care Fraud Statute prohibits knowingly and willfully attempting to carry out a scheme in connection with the delivery or payment of health care services, items or benefits that defraud any health care benefit program or obtains money or property under false pretenses or promises.

It is also noteworthy that per the Affordable Care Act, the federal Sentencing Commission is granted authority to increase sentencing guidelines by between 20 and 50 percent for any health care fraud crimes associated with more than $1 million in losses.

In defending these cases, it can be to your advantage that these laws are constantly changing and that regulations are very complex. Billing errors are sometimes the result of misunderstandings and nothing more. A well-formulated defense can greatly improve your chances of a favorable outcome.

Contact the Medicare Fraud Defense Lawyers at Jacobs Keeley Trial Lawyers for a confidential appointment to discuss your rights.

Call us at (305) 358-7991.

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