Medicaid and Medicare are funded by tax dollars at state and federal levels. The programs are designed to ensure vulnerable people, including those with low incomes, are able to receive healthcare. When people are given benefits that they are not entitled to, tax dollars are wasted and services are taken from people who need them.
Medicare/Medicaid fraud is the intentional misrepresentation or deception of a health care provider while knowing that doing so will give them, or someone else, benefits.
There are different categories of Medicare/Medicaid fraud, including:
- Billing for patients who didn’t receive any services
- Billing for equipment or services that were not provided
- Billing for services and items that a patient no longer needs
- Overcharging for services or equipment
- Concealing associations or ownership in a related company
- Paying “kickback” for referrals
- Billing the same service more than once
- Ordering prescriptions and tests that are not needed
Laws and Penalties
The penalties for Medicare/Medicaid fraud can be very harsh. They often involve multiple offenses and these are often charged at both federal and state levels. Some of the possible laws and penalties include:
- Imprisonment: The prison sentence at federal level varies depending on how much money was involved. Fraud up to $120,000 carries a maximum prison sentence of one year. If it was above $400,000, sentences are usually between two and three years.
- Fines: Federal convictions carry fines equal or up to twice as much the actual loss. Individuals carry a fine of $250,000 and corporations carry a fine of up to $400,000, whichever is greater.
- Medical sanctions: Providers, including physicians, are likely to lose their professional license and can be barred from any future contracts with Medicare/Medicaid for life.
- Multiple counts: Every single false claim is an individual offense. If dozens or hundreds of billings have been done fraudulently, maximum sentences can be requested. Additionally, the same offense can be trialed at both federal and state levels.
- RICO prosecutions: Additional criminal penalties can be carried if fraud falls under RICO, as well as forfeiture of assets.
- Civil lawsuits: Some fraud offenses can also be sued under RICO civilly, which can lead to triple damages.
Medicare/Medicaid Fraud Defenses
The reality is that the procedures for billing Medicare/Medicaid are incredibly complicated. There are new codes every year, and the way they are interpreted can be confusing. Indeed, the majority of medical offices outsource their coding in order to do it properly. At the same time, however, many of these companies where the work is outsourced can still have problems. However, this is a common defense.
Another common defense is that the patients who have been billed simply do not remember that they had treatment. Elderly patients, for instance, can often get confused. It is incredibly hard to prove that a procedure did not take place, particularly if your own records are not in order.
If wrongdoings have been committed, a good lawyer can petition the government not to take action, or at least not to prosecute. Essentially, a pre-trial diversion can be requested, which means criminal prosecution is avoided. However, restitution and fines usually have to be paid. Additionally, these agreements are usually only made to avoid prosecution against a full organization, such as a hospital, meaning the individual can still be criminally prosecuted.
Statute of Limitations
There is a statute of limitations on most, although not all, crimes. The statute of limitations for fraud, however, is particularly complicated. This is because the statute often doesn’t start running until it has been discovered that fraud has been committed. Hence, although the statute tends to be five years, this period starts after discovery of the fraud. Furthermore, the statute can be tolled if the person under investigation is out of state.
Medicare/Medicaid Fraud Cases
- Medina Elementary principal charged with health care fraud – The principal of an elementary school has been charged with Medicare fraud. His wife and one other person have also been charged. Allegedly, they claimed on wheelchair payments and also made kickback payments in order to get benefits.
- Two South Florida doctors and their wives to pay $1.13M in health care fraud settlement – Two doctors from south Florida have made an out of court settlement together with their wives in relation to accepting kickbacks from others.
- Jurors convict South Florida psychiatrist and patient recruiter in Medicare fraud trial – Psychiatrist Barry Kaplowitz was found guilty of lying about giving treatment to mental patients. However, he was acquitted of wire fraud and the primary charge of conspiring to bilk the Medicare program. He could face up to 25 years in jail on the charges he has been convicted on.
- Miami man pleads guilty to $8M Medicare Fraud scheme – Orelvis Olivera has pleaded guilty to the charge of Medicare fraud and will be sentenced in April.
- Fake doctor imprisoned 17 years for Medicare fraud in Florida – Alejandra Collazo posed as a doctor for several years after stealing the identity of other doctors in a “catch me if you can” scheme.