What is Medicare fraud?

Since its inception in 2007, the Medicare Fraud Strike Force (MFSF) has cracked down on Medicare Fraud. Two of the nine national MFSF operating centers are in Florida, including one in Tampa. To date, over 2,100 people have been indicted for some type of Medicare fraud, resulting in the recovery of approximately $2 billion.

A Medicare fraud conviction can mean long-term imprisonment and substantial fines. Healthcare providers charged with fraud can call Goldman Wetzel in St. Petersburg to speak to an insurance fraud defense lawyer. Contact us today at 727-828-3900.

What is Medicare fraud?

In § 455.2, the Code of Federal Regulations defines Medicare fraud as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.”

Some of the federal laws governing Medicare fraud include the False Claims Act (FCA), the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), and the Social Security Act.

Fraud typically involves submitting false claims to obtain a payment the provider is not entitled to, offering or receiving kickbacks for Medicare items or services, or making prohibited referrals.

Below are just a few examples of activities that can lead to Medicare fraud charges:

  • Billing for services not rendered or billing for more complex or expensive services than those that were rendered (up-coding)
  • Falsifying records to suggest a patient received goods or services that he or she did not receive
  • Paying for referrals
  • Submitting claims for ghost patients (patients who do not exist)
  • Billing for durable equipment not prescribed by doctors
  • Unbundling (billing for services separately instead of as a group)
  • Duplicate billing
  • Performing unnecessary treatments or tests
  • Submitting a claim on behalf of another provider who is ineligible to participate in the Medicare program
  • Violating the physician agreement

What are the penalties for Medicare fraud?

The penalties for Medicare fraud depend upon the nature of the charges, number of offenses, and whether the defendant is an individual or an organization. For example:

False Claims Penalties 

Those charged with filing false claims face paying back up to three times the amount taken from Medicare and $21,000 for each claim filed. They can also face jail time. 

Kickback Penalties 

Those charged with receiving kickbacks face civil penalties of $50,000 per kickback and paying back up to three times the amount of the kickback.

They can also face up to $25,000 and/or to five years in prison for each violation.

Stark Law Violation Penalties 

Physicians who violate the Stark Law (prohibited referrals) can face:

  • $15,000 for each service
  • Fines of up to three times the amount

Where can I get help with my Medicare fraud case?

It is critical to get the attorneys at Goldman Wetzel on the case as soon as possible. If you have received an audit in the mail, now is the time to contact us. Before charges have been filed, we may be able to avoid a larger investigation by negotiating a quick resolution. If charges have already been filed, it is all the more important to talk to one of our defense attorneys to protect your reputation, livelihood, and legal rights.

Contact Goldman Wetzel today at 727-828-3900.