Medicare Fraud: Whose Fault is it, the Patient or Doctor?

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Medicare fraud costs U.S. taxpayers about $60 billion annually, so it’s easy to see why the government has been trying to crack down on the issue.

However, not everyone accused of Medicare fraud is guilty of purposely misleading the government. Some simply made billing mistakes or were unknowingly used as pawns in someone else’s scheme. If you’re facing an accusation, your attorney will share common types of fraud and identify the party at fault.

What is Medicare Fraud?

Medicare fraud, classified as a white-collar crime, involves the deliberate and deceptive exploitation of the Medicare system for financial gain. It encompasses various fraudulent activities perpetrated by individuals or entities, including healthcare providers, suppliers, and beneficiaries, to unlawfully obtain payments or benefits from Medicare.

How Health Professionals Commit Medicare Fraud

There are a few common ways medical professionals defraud the Medicare program. One method is upcoding, in which a doctor uses the wrong code for a medical procedure because it costs more, which will, in turn, get the practice a larger reimbursement from Medicare.

In another type, the doctor performs the more expensive procedure they bill for, but only because it costs more — not because the patient actually needs it. This results in a higher payout from Medicare.

Examples of Medicare Fraud Involving Doctors and Healthcare Providers

  • Billing for Services Not Rendered: Doctors submit claims to Medicare for services or procedures never provided to patients.
  • Unbundling Services: Healthcare providers improperly unbundle procedures or services to maximize Medicare reimbursements, billing for each component separately instead of using bundled codes.
  • Kickbacks and Referral Schemes: Doctors receive kickbacks or payments in exchange for referring patients to specific providers or facilities for unnecessary services covered by Medicare.
  • False Diagnosis: Healthcare providers falsely diagnose patients with medical conditions to justify unnecessary treatments or services billed to Medicare.
  • Falsifying Medical Records: Doctors and healthcare providers alter medical records or documentation to support fraudulent claims submitted to Medicare.

Some doctors don’t actively set out to defraud Medicare, but they do it anyway by failing to return overpayments. Others accidentally bill Medicare for too much money, at which point they’re supposed to report the problem — not just keep the cash. In this way, you might be accused of Medicare fraud by simply not taking action after an overpayment.

How Patients Commit Medicare Fraud

As you might imagine, it’s much easier for doctors and nurses to commit Medicare fraud than patients themselves. This is because medical practices are the ones billing Medicare for their services. However, occasionally, patients are accused of being complicit in Medicare fraud. In most cases, they had no idea they were participating in this action.

For example, a doctor might waive their deductible or copay and make up the difference by upcoding so Medicare pays more. In many cases, the patient is not aware of this action. But if there’s evidence they were, it can lead to Medicare fraud charges.

Another type of fraud that patients might commit involves kickbacks. This is when the patient gives a medical practice their Medicare number and is compensated with money or free products. The practice then bills Medicare for services the patient never got, which is how it pays for the patient’s cash or free products. In this type of scheme, both the doctor and the patient might be implicated.

Examples of Medicare Fraud Involving Patients

  • Knowingly Providing False Information: Patients intentionally provide inaccurate or false information to healthcare providers to obtain Medicare-covered services or prescriptions they are not entitled to.
  • Medical Identity Theft: Patients allow others to use their Medicare identification numbers to submit false claims for never rendered or received services.
  • Upcoding: Patients collaborate with healthcare providers to inflate the severity of their medical conditions or services received, resulting in higher Medicare reimbursements.
  • Doctor Shopping: Patients visit multiple doctors or healthcare facilities to obtain duplicate or unnecessary services, which are then billed to Medicare.

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Legal Consequences and Penalties for Medicare Fraud

Medicare fraud is a serious offense that can result in severe legal consequences for individuals and entities guilty of fraud. The legal penalties for Medicare fraud can vary depending on the nature and extent of the fraud, but they often include:

  • Criminal Charges: Individuals and organizations engaged in Medicare fraud may face criminal charges brought by federal prosecutors. Common charges include healthcare fraud, conspiracy to commit fraud, false claims, and wire fraud.
  • Imprisonment: Convictions for Medicare fraud can lead to significant prison sentences. Those found guilty may face several years of incarceration, particularly for large-scale fraud schemes.
  • Fines and Restitution: Perpetrators of Medicare fraud may be required to pay substantial fines and restitution to reimburse Medicare for the fraudulent claims submitted. Fines can amount to millions of dollars, depending on the scope of the fraud.
  • Exclusion from Medicare Programs: Individuals and healthcare providers convicted of Medicare fraud may be excluded from participating in federal healthcare programs, including Medicare and Medicaid. This exclusion can have devastating consequences for healthcare professionals and organizations.
  • Civil Monetary Penalties: In addition to criminal penalties, perpetrators of Medicare fraud may be subject to civil monetary penalties imposed by the government. These penalties deter fraudulent behavior and recover funds lost due to fraudulent claims.
  • Professional License Revocation: Healthcare professionals found guilty of Medicare fraud may face disciplinary actions, including the revocation or suspension of their professional licenses. This can severely impact their ability to practice medicine or operate healthcare facilities.

Seek Legal Assistance from Experienced Attorney Seth Kretzer

Regardless of who is being charged with Medicare fraud, the consequences of a conviction are serious. This can be a shock if you don’t believe you committed this crime or were unknowingly part of a Medicare scam. You need someone on your side to help you fight these charges. So, if you’ve been charged with Medicare fraud, reach out today to set up a free consultation during which we can discuss your case.

Legal issues can arise anywhere. Seth Kretzer, nationwide attorney, is ready to help – contact our firm now!

Phone: 713-775-3050
Fax: 713-929-2019
Houston, TX 77002
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