Medicare-Medicaid Fraud – Crime And Punishment Q & A

Q. What is Medicare-Medicaid Fraud and what are the penalties?

A. Medicare-Medicaid fraud is defined broadly as the criminal acts committed by those who seek compensation from the Medicare-Medicaid health systems through illegal means. Criminal filings and convictions against health care professionals and companies have increased dramatically in recent years.

Over the past decade,  a series of major federal stings resulted in over one thousand arrests of doctors, nurses, speech therapists, including health care company executives and owners. Federal prosecutors had over 2,000 health-fraud probes open at the end of 2013.

Difference Between Medicare And Medicaid

There has been a great deal of confusion regarding the distinction between Medicare and Medicaid programs.  Both public healthcare systems involve the federal government.

Medicare is a federal program derived from nations social security program and is available to those 65 years of age or older. Medicare is available based on age and not income.

Medicaid is a joint federal and state program designed to assist low-income individuals and families. The federal government, working with state healthcare programs contributes up to 50% of the state’s Medicaid program.

Types Of Medicare-Medicaid Providers Charged With Fraud

Medicaid providers that have been charged and convicted of Medicare-Medicaid fraud include doctors, dentists, hospitals, nursing homes, pharmacies, clinics, and any other individual or company that is paid by either the Medicare or the Medicaid program.

Types Of Medicare–Medicaid Fraud

Fraud, theft, and conversion have been found in the following types of health provider services and include:

Phantom Billing: Includes fraudulent charging for services that were not performed.

Upcoding: Includes the fraudulent classification in the billing of services by upcoding certain services that are neither indicated nor reasonably necessary.

Unbundling: Includes the fraudulent billing for individual services where the billing of less expensive multiple bundled services were indicated.

Double Billing: The fraudulent double billing for the same medical service;

Drug Switching: The fraudulent dispensing by pharmacists of generic drugs but billing Medicare-Medicaid for the higher paying brand-name drugs.

Criminal Penalties For Medicare Fraud

Those charged and convicted of Medicare-Medicaid fraud face both fines, jail terms and the loss of their professional license. Fines range from $10,000 to $500,000 or more depending on the severity and duration of the fraud. In addition to fines, those who are convicted of Medicare-Medicaid fraud are usually required to pay back all funds that were frequently acquired. These repayments may be equal to or even more than the amount of fines imposed depending on the extent and nature of the fraud.

Those who are charged and convicted of Medicare fraud face up to five years in prison per offense, which can run consecutively. Therefore each offense can be stacked which can result in a life sentences. However, the courts have substantial discretion in sentencing where the interests of justice dictate otherwise.

Finally, those healthcare professionals convicted of Medicare-Medicaid fraud face loss of their professional license by their respective professional administrative boards.

How To Report Medicare Fraud

If you discover charged items or services listed in your claim forms which are not associated with your care or treatment, it’s possible you may have been fraudelently billed for such services or items and you should report it to the Medicare authorities.   If you suspect fraud call: 1‑800‑447‑8477.

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