One of the most troubling accusations that can be brought against a provider is Medicaid/Medicare fraud. If you’re found guilty of fraud, the consequences can be severe: Medicare or Medicaid fraud typically comes with civil or criminal charges, which can lead to fines or even jail time.
Any kind of Medicare or Medicaid provider may be charged with fraud, including doctors, dentists, pharmacies, care facilities and so forth. The charges may be brought on the state level, or they may be federal charges (or both).
Reducing Your Risk of Accusation
The best defense is to make sure you’re above scrutiny. Several kinds of activities are red flags that draw the attention of government auditors. Some show malice, while others may be the result of shoddy bookkeeping.
Essentially, Medicare and Medicaid want you to represent the services you provide accurately. They want you to only bill for services and visits that took place, for instance, and they want you to only bill for each service once. Certain billing practices, like claiming that you provided more than 24 hours of service in a day, will raise a red flag.
In the reports you file to Medicare or Medicaid, you need to accurately report all information about the service and product. For instance, if you are a pharmacist and you dispense a generic drug, you cannot tell the government that you provided a name-brand drug.
Finally, one serious kind of Medicare or Medicaid fraud is kickbacks. Some providers will file fraudulent claims with the government, then pay a sum of the resulting money to the patient in return for them staying quiet about the fraud. This is clearly malicious and obviously illegal, and can backfire on you if an employee or someone you’re paying out sues you or files a whistleblowing complaint with the government (sometimes called a qui tam complaint or lawsuit).
To head off problems at the pass, you should always make sure your documentation is thorough and up-to-date. You should have extensive records of services provided, money you paid and received, and so forth.
If you’re in doubt about a service you provided or a drug you dispensed and your records don’t have sufficient information, you should generally report the most conservative information you have to the government, and not embellish from memory. You will never be accused of Medicaid or Medicare fraud for underbilling the government, but overbilling can be a serious offense.
If you have no information about a service you provided at all, you should avoid filing a Medicare or Medicaid claim entirely. Even if you are making a conservative guess as to the services you provided, if you are audited and cannot present information, it will look as though you falsified the information.
When You’re Accused
If you’re accused of Medicare fraud, you may be subjected to an audit. If you’re audited, you should give all information you have, regarding the dates or services in question, to investigators.
If you’re under investigation, you may also be interviewed. You are expected to answer all questions completely and honestly, but be aware that many government agencies will only open an investigation when they’re sure they can get incriminating information by conducting it.
Because Medicare and Medicaid fraud is a serious crime with grave consequences, you should always hire an experienced Houston federal criminal defense lawyer as early as you can in the process, even if you know you have done nothing wrong. A lawyer will serve as your health care fraud defense and will give you good advice about your route forward.
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