What is Medicare Fraud?

Medicare provides health insurance for tens of millions of seniors. In fact, the Centers for Medicare and Medicaid Services is the single largest provider of health insurance in the United States. As such a large government program, it is ripe for abuse, and arrests for Medicare fraud frequently make the news.

With prosecutors believing they can receive good press for bringing criminal charges, many innocent defendants will be caught up in wide-ranging stings. If you have been arrested for Medicare fraud, you need an experienced Knoxville criminal defense attorney to represent you.

Types of Medicare Fraud

Health professionals have been caught bilking money out of Medicare by using different schemes. Some of the more common have included:

  • Billing for unnecessary procedures. For example, a doctor has already diagnosed a patient but decides to order several other tests so that he can bill them, even though they are not necessary.
  • Billing for procedures that are never performed. A doctor could bill for having patients undergo an MRI although none actually had the procedure.
  • Double billing. A provider might bill Medicare and then also charge the patient, so the provider ends up getting paid twice.
  • Purchasing unnecessary equipment or used equipment that is billed as new.
  • Using incorrect billing codes to inflate the bill. This is another way to inaccurately record what medical services were actually provided.
  • Substituting a generic drug for a prescription drug, but billing for the prescription drug, which costs more.

Sometimes, patients are in on the scheme and receive a percentage of the proceeds as a kickback, which is also illegal.

Fraud is usually intentional though inaccurate billing can sometimes be unintentional, especially if a doctor is new and does not understand how to bill accurately. Either way, the federal government takes inaccurate billing seriously and could investigate you for fraud if you submit too many bills with mistakes. Your best bet is to hire a criminal defense attorney in Knoxville immediately.

The Government’s Response to Medicare Fraud

Medicare fraud is so widespread that the federal government has created Medicare Fraud Strike Force teams that operate in dozens of cities around the country. In 2018, the federal government created a strike force for Appalachia which is focused on the illegal prescription and distribution of opioids.

Each Strike Force uses a data-driven approach that analyzes billing to identify any suspected fraud swiftly. The Office of Inspector General, which oversees the strike forces, can work with the Centers for Medicare & Medicaid Services to halt payments to practitioners suspected of committing Medicare fraud.

The Strike Force approach has been remarkably successful, arresting thousands of criminals and halting fraudulent schemes that have bilked hundreds of millions of dollars from taxpayers. Some of the more high-profile arrests and convictions include:

  • A $1 billion scheme operated by a health care executive in Florida who operates nursing homes. As of February 2019, the defendant is currently standing trial.
  • A specialty pharmacy agreed to pay $17 million to settle claims that it overbilled Medicare for drug ingredients.
  • A company providing home dialysis treatment agreed to pay roughly $3.2 million to settle allegations that it had received kickbacks.

There are dozens of Medicare fraud stories published each month, which show the wide scope of the problem and justify the government’s aggressive response.

Penalties for Medicare Fraud

A conviction for Medicare fraud carries stiff penalties. The precise penalties will depend on which federal law the government uses to prosecute you:

  • The False Claims Act. This law allows private citizens to sue someone for committing fraud against the government, including against the Medicare program. Those who bring these cases can receive a share of the money, and the Act provides for treble damages, meaning that someone convicted might have to pay back three times what they stole from Medicare.
  • The Anti-Kickback Statute. This law makes it illegal to exchange something of value to reward or induce a referral. A conviction carries a fine of up to $25,000 and five years in prison. The government can also seek treble damages and a $50,000 penalty for every violation of the anti-kickback statute.
  • The Civil Monetary Penalty Law. The Inspector General can obtain monetary penalties up to $10,000 for every item that is improperly billed to Medicare. Also, a defendant can be excluded from participating in any federal health care program ever again.
  • The Stark Law. This law generally prevents a doctor from making a referral to a business that he or she has a financial relationship with.

Many of those arrested for Medicare fraud are looking at five years in jail for every offense and massive fines, as well as being required to pay back any overpayment they received. Even worse, defendants might be excluded from doing business with federal health insurance programs, which could bankrupt a business.

Help During an Investigation

If you end up on the government’s radar, then you will need immediate legal help. The federal government can overwhelm health care providers, especially smaller ones, with requests for information. Providers who have never been under threat of investigation might feel bullied and hand over information that the federal government actually has no right to without a subpoena.

Take control of the situation. An experienced Knoxville criminal defense attorney will stand between you and the federal government, ensuring that you maintain your confidentiality and give the government no more than it is entitled to. We can also go with you when you are interviewed by federal investigators. Remember that the government always has the burden of showing that you committed a crime, and you have no obligation to hand them evidence on a silver platter.

Contact a Knoxville Criminal Defense Attorney Today to Schedule a Free Case Evaluation

Bringing charges for Medicare fraud is a win-win for the government. Prosecutors can show they are tough on crime and defenders of abused taxpayers—even if they end up losing the case. And if they win, they can claw back overpayments and fill their coffers with massive penalties.

At Barnes Law, we are skilled at representing clients in federal investigations, including investigations for Medicare fraud. For immediate assistance, contact us today by calling 865-805-5703 or completing an online contact form. We offer a free consultation.