Medicare Fraud: Whose Fault, the Patient or Doctor?

Medicare fraud cost U.S. taxpayers about $16 billion in 2016 alone, so it’s easy to see why the government has been trying to crack down on the issue.

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

How Health Professionals Commit Medicare Fraud

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There are a few common ways in which 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 actually does perform the more expensive procedure he or she bills for, but only because it costs more — not because the patient actually needs it. This results in a higher payout from Medicare. Alternatively, some doctors don’t perform a medical service at all, but they still bill for it. For example, they might claim a patient needed a lab test done, so they bill Medicare for it, but in reality they never sent the patient to the lab at all.

Some doctors don’t actively set out to defraud Medicare, but they end up doing 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 end up being accused of Medicare fraud by simply not taking action after an overpayment.

Situations Where Patients Defraud Medicare

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. But 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 then 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 he or she was, it can lead to Medicare fraud charges.

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Another type of fraud that patients might commit involves kickbacks. This is when the patient gives a medical practice his or her Medicare number, and then 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 patient might be implicated.

Regardless of who is being charged with Medicare fraud, the consequences of a conviction are serious. They often include prison and steep fines. This can come as a shock if you don’t believe you committed this crime, or if you 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, contact us today to set up a free consultation during which we can discuss your case.


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Fax: 713-929-2019
Houston, TX 77002
440 Louisiana, Suite 1440