Medicare Fraud

Government Investigation: Civil or Criminal?

Medicare fraud is investigated in depth by many different parties, including the Office of Inspector General, the Department for Health and Human Services, the Department of Justice, the FBI, Medicaid Fraud Control Units, and State Medicaid Agencies.

If found guilty, both civil and criminal punishment could be in order depending on your specific situation. To paint a general picture, about 1,400 individuals are indicted while 2,500 are under Medicare criminal investigation, so the threat of criminal punishment is very real.

The best way to know what your specific situation entails is to really sit down and discuss it with you so that we can have a general idea. Just know that there is no guarantee that you will be under criminal investigation, so let us handle your case and determine the severity for you specifically.

What are Examples of Medicare Fraud?

There are many different examples of Medicare fraud, so it can be hard to keep track. Here are some commonly seen cases:

• Phantom Billing: this is submitting billing for services not provided and is one of the most common types of Medicare fraud. It could involve tests that were never taken, healthcare hours not provided, or even billing for patients who have already left or died.
• Double Billing: this is when the provider attempts to bill the patient, insurance company, or Medicare multiple times for the same treatment.
• Falsification of Cost Reports: this involves adding personal expenses under the guise of professional expenses related to treatment of patients. Cases of this have included billings for new cars, renovations, or other personal costs.
• Falsification of Patient Records: this can be done in order to falsely prove a need for gratuities treatments, prescriptions, or even surgeries for the sole purpose of billing.
• Kickback Fraud: this refers to instances when laboratories or pharmaceutical companies offer kickbacks through money, gifts, or products to providers in exchange for referrals.
• Physician Self-Referrals: as mentioned earlier, physicians may not offer referrals to facilities with which they have a conflict of interest (they or an immediate family member have financial involvement).

What is the Medicare Appeals Process?

With the complexity of Medicare fraud cases, there is, of course, an appeals process to understand as well. Taking on this process without experienced attorneys is a massive mistake that could lead to costly risks and penalties, many of which could be avoided.

The steps of the Medicare appeals process are:

• Redetermination by a CMS contractor (Centers for Medicare & Medicaid Services)
• Reconsideration by a qualified contractor
• Hearing before an administrative law judge
• Review by an appeals council
• Judicial review in federal district court

All five steps require meticulous care and attention to provide the correct evidence and argument to ensure success in moving forward. Be sure to have an experienced lawyer making these steps with you so that you are informed and prepared.

Book you free consultation with us to get started!