What Is Considered Medicaid Fraud

Florida: Medicaid Fraud Penalties

Section 409.920 of the Florida Statutes imposes criminal penalties for all forms of Medicaid fraud, including overbilling Medicaid as well as paying and receiving kickbacks in connection with Medicaid-reimbursed services, equipment, and supplies. The criminal penalties for Medicaid fraud in Florida include:

• All cases: A fine in an amount equal to five times the pecuniary gain unlawfully received or the loss incurred by the Medicaid program or managed care organization, whichever is greater.
• First-degree felony : $10,000 fine and 30 years of imprisonment
• Second-degree felony : $10,000 fine and 15 years of imprisonment
• Third-degree felony : $5,000 fine and five years of imprisonment

What Is Medicare Fraud

Medicare Fraud, also known as Health Care Fraud, involves the swindling of health care claims for a goal to profit. Categorized as one of the common white-collar crimes in the United States, Medicare Fraud can be manifested in various ways.

It includes, but not limited to: kickback schemes self-referral doctor shopping identity fraud layering upcoding and unbundling submitting double bills billings for services not provided.

Medicare And Medicaid Fraud Whistleblower Faq

Medicare/Medicaid fraud means a medical provider doctor, dentist, hospital, hospice care provider or nursing home makes a fraudulent reimbursement claim. The most common types of fraud include: billing for unnecessary procedures or procedures that are never performed for unnecessary medical tests or tests never performed or for unnecessary equipment.

Any persons or entities with evidence of fraud against federal programs or contracts may file a qui tam lawsuit. However, if the government or a private party has already filed a False Claims Act lawsuit based on the same evidence of Medicare and/or Medicaid Fraud as you, you cannot bring a lawsuit.

A qui tam action must be confidentially filed under seal in federal district court in accordance with the Federal Rules of Civil Procedure. A copy of the complaint, with a written disclosure statement of substantially all material evidence and information of Medicare and/or Medicaid Fraud in the plaintiff’s possession, must be confidentially served on the US Attorney General and the US Attorney for the district in which the complaint is brought. An action under the False Claims Act must be filed, in camera and under seal. The complaint and its contents must be kept confidential until the seal is lifted. The complaint is not served on the defendant. If the plaintiff violates the provisions of the seal, his or her complaint could be dismissed.

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Reporting Fraud And Abuse

These examples of Medicaid fraud and abuse sound similar. Figuring out the difference between Medicaid fraud and abuse requires investigation. If you know or believe that Medicaid fraud or abuse is happening, please report it so it can be properly investigated. If you want to make a report, you can remain anonymous, but sometimes we may need to contact you in order to conduct an effective investigation. Your name will not be shared with anyone who is being investigated, but in rare cases involving legal proceedings we may have to reveal who you are.

Helpful information to include in a report:

• The name or names of the members.
• The name or names of the providers.
• The date or dates of the services.
• A description of the acts that you suspect involve Medicaid fraud or abuse.

How to report Medicaid fraud and abuse:

• Contact the Division of Medical Assistance by calling the DHHS Customer Service Center at 662-7030.
• Complete and submit a Medicaid fraud and abuse confidential online complaint form by going to the DHHS Customer Service website.

Texas: Medicaid Fraud Penalties

In Texas, Medicaid fraud can be charged as a civil violation, a misdemeanor, or a felony offense depending upon the specific circumstances involved. In each type of case, potential penalties include:

• All cases: Exclusion from Medicaid program eligibility
• Civil: Civil monetary penalties
• Felony: Tens or hundreds of thousands of dollars in fines plus five years of imprisonment for each violation
• Misdemeanor: Tens or hundreds of thousands of dollars in fines for each violation

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Michigan: Medicaid Fraud Penalties

Michigan, similar to California, has several laws that MFCUs and other authorities can use to prosecute cases of Medicaid fraud. Some of these laws include:

• Health Care False Claims Act : Fines up to $50,000 and four years of imprisonment per violation
• Medicaid False Claims Act : Fines up to $30,000 and four years of imprisonment per violation
• Physician Division of Fees : Misdemeanor fine of up to $750 and up to six months of imprisonment, loss of license for a second offense

How Can Medicare Fraud And Abuse Be Prevented

Its very important to keep your Medicare number private and secure. You need to keep all your medical records protected. If you notice a doctor trying to provide services you dont need, say something and report the issue to Medicare.

When you get the NOT A BILL letter that goes over all the services youve received from your healthcare visit, its important to review that. Make sure everything on the paper lines up with the services that were provided.

Many people just throw this paper away, leaving scammers to keep scamming the system.

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Preventing Fraud And Abuse

• Your Medicaid card and number are yours. Do not let anyone else use them.
• Do not give your Medicaid number to a stranger or in exchange for a special offer.
• Remember that Medicaid does not pay for mentoring, after-school programs, summer camps, or tutoring.
• Ask for a written description of the services offered to you.
• Do not agree to services that you do not think you or your child need.
• Do not sign a blank form.
• Write down the names of the people that provide your services, the agencies they work for, and the dates the services are provided.

Making Sure You Have The Medicare Coverage You Need

If you want to be more secure in the total health care coverage you receive, then a Medicare Supplemental plan could be the key to that. Medigap can close up any holes in your Medicare.

Speaking with one of our licensed insurance agents can make that process much easier and arm you with the knowledge needed to make the best decision for your health care.

Our licensed agents are free to contact, so you can ask whatever Medicare-related questions you have. Give us a call today, or fill out our quick and easy online rate form to be connected with the best plans in your area.

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What Are The Corresponding Statutes Penalizing Medical Fraudulent Activities

Fair Claims Act

False Claims constitute, including but not limited to knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval or knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim.

Whoever makes or presents to any person or officer in the civil, military, or naval service of the United States, or to any department or agency thereof, any claim upon or against the United States, or any department or agency thereof, knowing such claim to be false, fictitious, or fraudulent, shall be imprisoned not more than five years and shall be subject to a fine in the amount provided in this title.

Stark Law

The Stark Law aims to prohibit a physicians referral to a particular and designated health care service to a certain entity if the physician has a financial relationship with the same unless otherwise provided by the law.

Anti-Kickback Statute

Anti-Kickback statutes are designed to prohibit the knowing and willful payment of remuneration to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal healthcare programs .

The law says that remunerations include anything of value and can take many forms besides cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies.

Civil Monetary Penalties Law

Criminal Fraud Statute

Defenses Against Medicaid Fraud Charges

In order to prove that you committed fraud against the Medicaid program, the prosecutor will have to prove the following under the False Claims Act : evidence that the defendant knowingly and purposefully 1) made a claim or statement to get the government to pay money on a claim and 2) that the claim or statement was false or fraudulent.

In response, your healthcare defense attorney can exhibit the following defenses depending on your case:

• Lack of intent: The defendant did not knowingly or intentionally commit the fraudulent action.
• Consent: A victim/patient accuses you of Medicaid fraud, but you have documentation that the person accusing you consented to the medical steps you took to treat them.
• Insufficient evidence: Whether you intended to commit healthcare fraud or not, there needs to be enough evidence to prove your intent beyond a reasonable doubt. If theres not enough evidence, then theres no case against you.
• Voluntary disclosure: Reporting yourself to the agencies that oversee fraud can potentially lower your chances of receiving heavy fines, but it is still a risky choice. ALWAYS consult with an attorney before deciding whether or not to turn yourself in.

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State Penalties For Medicaid Fraud

The penalties for Medicaid fraud under state law vary significantly from one jurisdiction to the next. At the state level, Medicaid fraud cases are investigated and prosecuted by Medicaid Fraud Control Units , Offices of the Attorney General, and various other authorities. Below are the potential penalties in some of the states with the heaviest focus on Medicaid fraud enforcement.

Faq On Medicare And Medicaid Fraud

• How to report Medicaid fraud?

Please report any Medicaid fraud or abuse you may be aware of or suspect so that a thorough investigation can be conducted. Learn where and how to report. Start by selecting the one that most accurately describes your circumstance:

• Dial 727-6721 to reach the Alliances confidential Fraud and Abuse Line.
• Dial 662-7030 to reach the Division of Medical Assistance at the DHHS Customer Service Center.
• Dial DMA-TIP1 or 362-8471 to contact the Medicaid Fraud, Waste, and Program Abuse Tip Line.
• Dial 730-TIPS or 730-8477 to reach the State Auditors, Waste Line.
• Visit the DHHS Customer Service page, fill out the confidential online complaint form regarding Medicaid fraud and abuse, and submit it

• What happens if you get caught lying to Medicaid?

The following is a list of the possible outcomes if you are found to have lied to Medicaid:

• The DSS HRA Bureau of Fraud Investigations will send you an investigation letter.
• The funds you got from the HRA must be returned to them.
• You risk up to seven years in prison.
• A fraud conviction might result in a felony on your record and prevent you from ever getting Medicaid again.
• Your Medicaid benefits will end.

• What entities can be considered legally guilty of Medicaid fraud?

According to CMS, healthcare entities and providers are people or organizations accepting Medicaid funding for rendering services. They include:

Any of these are capable of engaging in Medicaid fraud and being found responsible for it.

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How To Avoid Committing Medicaid Fraud

As you can see, there are several types of fraud when you accept Medicaid payments. If you want to avoid any accusations against your practice, its helpful to begin by making sure your entire staff knows the importance of only billing for services rendered to patients. Stress how crucial it is for them to complete coding and billing accurately, and to keep records of all patients diagnoses and treatments.

You should also steer clear of any conflicts of interest including kickbacks when it comes to providers to whom you refer patients, vendors who keep your office stocked with products and other medical providers your practice might work with. If youre not sure if you have any conflicts of interest that would look bad to the government, consider whether youd be okay with your arrangement making front page news. If not, you should avoid the situation to ensure that no one thinks youre committing fraud.

Tips For Avoiding Health Care Fraud

• Protect your health insurance information. Treat it like a credit card. Don’t give it to others to use, and be mindful when using it at the doctors office or pharmacy.
• Beware of free services. If you’re asked to provide your health insurance information for a free service, the service is probably not free and could be fraudulently charged to your insurance company.
• Check your explanation of benefits regularly. Make sure the dates, locations, and services billed match what you actually received. If theres a concern, contact your health insurance provider.

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Examples Of Medicare And Medicaid Fraud

Charging the government for medically unnecessary drugs, procedures, or tests in order to profit is one example of healthcare fraud. In 2022, for example, a Florida man who owned and operated several telemedicine platforms was sentenced to 14 years in prison for fraud that cost Medicare more than $20 million dollars. He marketed and prescribed medically unnecessary genetic tests to Medicare beneficiaries in exchange for kickbacks and bribes. The accused knew that the genetic laboratories involved would bill Medicare for medically unnecessary goods and services.

Another way of committing fraud is to impersonate a licensed provider. For example, in 2022, a Texas woman was accused of using her ex-husbandâs provider number to submit fraudulent claims to Medicaid for counseling services that were never provided, receiving more than $600,000 in fraudulent claims.

About Medicaid Fraud Waste And Abuse

Medicaid fraud and abuse affects all New Yorkers by depleting valuable public funds meant to provide healthcare to vulnerable citizens. The New York State Office of the Medicaid Inspector General is a nationally recognized leader among Medicaid program integrity agencies. OMIGs recovery efforts and cost-containment initiatives save hundreds of millions in taxpayer dollars each year.

New Yorkers can assist OMIG in fighting fraud, waste, and abuse by reporting potentially suspicious behavior or incidents. OMIG encourages anyone who observes instances of potential Medicaid fraud, waste, or abuse to contact OMIGs fraud hotline. Tips can be completely anonymousand OMIG investigates all reported information.

Healthcare fraud is not a victimless crime. It impacts all New Yorkers.

Taxpayers: Even the lowest estimates of healthcare fraud represent an enormous drain on the public health care system. Taxpayers in New York State and throughout the country pay the price.

Recipients: When a provider misrepresents his or her credentials and services, it can jeopardize your health. By falsifying or exaggerating a diagnosis, a doctor may add a condition to your medical record you don’t even have. You can be subjected to unnecessary or unsafe medical procedures, may receive the wrong medical treatment, or find that your health benefits have been exhausted.

Examples of recipient fraud include:

Examples of provider fraud include:

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Medicaid Fraud Control Unit Frequently Asked Questions

Effective July 1, 2011, the Georgia Medicaid Fraud Unit has been consolidated under the Georgia Department of Law pursuant to an Executive Order by the Governor. Previously, the unit was composed of a three agency task force that included the Georgia Department of Law, the Georgia Bureau of Investigations and the Georgia Department of Audits.

If you suspect that Medicaid fraud may be occurring, report it to the Georgia MFCU.

Who Are Potential Persons To Be Investigated

The law provides that statutes apply to any individual or business, directly or indirectly, contracts with and is paid for services regulated by the US government.

Health care Fraud exposes providers and business owners alike. Statutes apply to any individual or business that directly or indirectly contracts with and is paid for services by the United States government. Particularly exposed are service arrangements with the government in the following areas:

Industries:

• Health care Providers

• Medicare Fraud Strike Force charges 90 individuals
• Medicare Fraud Strike Force charges 89 individuals
• Doctor Admits Taking Bribes in Test-Referral Scheme with Lab
• Owner of Nursing Agency Convicted of Multi-Million Dollar Fraud Scheme
• Principal in $28.3m Medicare Fraud Scheme Sentenced to 11 Years in Prison

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Are You Facing A Medicaid Fraud Investigation

If you are being investigated by an MFCU, the U.S. Department of Justice , the Office of Inspector General of the U.S. Department of Health and Human Services , the Drug Enforcement Administration , or any other state or federal law enforcement authority, it is important for you to retain experienced, effective legal representation. If you have not yet been charged, you need to do everything in your power to avoid having your investigation lead to civil or criminal prosecution.

At Oberheiden, P.C., we have decades of experience representing clients in Medicaid fraud investigations, and several of our senior attorneys worked for the DOJ and state prosecutors offices before entering private practice. Once you get in touch, we will quickly make contact with the investigating authority in order to intervene in the investigation. As soon as we determine the specific allegations against you, we will then develop and execute a customized defense strategy designed to resolve your investigation without charges and without long-term impact to your business or practice.