Last Updated on: 26th February 2023, 10:26 am

It is difficult to track the amount of money healthcare programs pay as a result of Medicaid and Medicare fraud and abuse, thus wasting the US federal budget. Therefore, the US law enforcement places high priority on auditing, investigating and prosecuting cases of healthcare fraud. Thus, it is important to learn about what to do in order to avoid it, what can trigger such investigations and what to do if targeted by the authorities.

Medicare Fraud: Definition and Its Types

First of all, it is necessary to figure out the difference between Medicare fraud and Medicare abuse and what constitutes each of them.

Medicare fraud

It is a situation when services provided by the healthcare programs are deliberately misrepresented in order to obtain profit. The common types are the following:

• intentionally billing for services other than the patient actually received;
• paying for referrals.

Medicare abuse

It is a situation when patients are either intentionally or unintentionally prescribed unnecessary medical services, or these services either don’t meet the necessary standards or are not priced correctly.

Both of the above can result in criminal prosecution or civil litigation.

Another type of division of healthcare fraud stems from who performs the crime, with major types being the following:

• committed by provider, for instance, falsification of a diagnosis, prescribing unnecessary tests, prescribing medicines to be later used by someone other than the patient, etc.;
• committed by patient: providing false details to apply for healthcare services or supplies; forging or altering receipts, etc.;
• committed by insurer, for example, denying valid claims, providing misleading information about benefits, etc.

Medicare Fraud and Abuse Related Legislative Documents

Compliance with the standards of the national healthcare programs are regulated by the following laws:

• False Claims Act (FCA), which protects the US government from being excessively charged for services provided to the citizens through healthcare programs and also sold medical services or supplies that do not correspond to the necessary standards;
• Anti-Kickback Statute (AKS) and Physician Self-Referral Law (Stark Law), which ensure liability of those who intentionally engage in providing referrals for medical services or supplies for the purpose of gaining profit.

Other legislative documents also include Social Security Act, United States Criminal Code, Civil Monetary Penalties Law, and Criminal Health Care Fraud Statute.

These documents provide that those found guilty of fraud may be sentenced to imprisonment, large fines or other penalties. As you see, medicaid and Medicare fraud are serious crimes, and if a person is under investigation for them, they would definitely need assistance of a Medicaid fraud attorney.

How to Avoid Medicare Fraud

Guidelines for healthcare professionals

• Be aware of the law. Even if you are not aware of the fact that some of your actions or those of your employees might be fraudulent, it won’t absolve you from the liability in the end. You can find the list of laws applying to your practice above. Pay special attention to the first two points on the list.
• Make sure the billing and coding practices are in order. Regularly check the records for mistakes, and if any, be sure to disclose them to your employer who then should pass this information on to a regulatory agency that your workplace reports to.

Guidelines for healthcare programs beneficiaries

• Be aware of the law and read carefully all papers you sign when applying for healthcare benefits. Ask questions if any, to know your rights and obligations.
• Only disclose your Medicare number and Social Security card number to authorized healthcare providers.
• Mark the dates of all appointments on a calendar. Check Medicare statements for errors.
• Don’t ask for services you don’t need.
• Report suspected fraud.

What to Do If You Become a Medicare Fraud Victim

How to report it

Healthcare fraud not only costs our country billions of dollars annually but also puts the health of US citizens at risk. Therefore, US citizens are encouraged to report such cases. If you suspect that some dates or services on Medicare statements are incorrect, please follow these guidelines:

Contact your healthcare provider and try to figure out the inaccuracies in your statement. This way, a billing error may come up, and the provider will set things right.

If you still suspect that fraud is involved, you can report it by contacting the Office of Inspector General by calling 1-800-447-8477 or via its official website.

Provide as many details about the alleged fraud as possible. This includes your name and card number, details about your healthcare provider, date of the healthcare service you have doubts about and its cost. Also describe what acts exactly seem to be fraudulent.

What to do if targeted by the investigators

The common reason why recipients of healthcare benefits are targeted by fraud investigators is that they failed to disclose their full income on the application, and the real amount of their income implies they are not eligible for the benefits. Another reason may be the fact that they receive treatment in an institution that doesn’t correspond to their actual place of residence. Patients are notified that investigation is under way by a letter requesting them to come to an investigation interview.

If you find yourself in such a situation, we recommend you to follow these guidelines:

• Do not ignore the letter.
• Do not come to the interview and speak to the investigator, you don’t have to. By the time you receive the letter, the authorities have already gathered a lot of information about you. Still, they might be missing some important information or documents, which prevents them from starting a case against you. So any details or documents you disclose can incriminate you gravely.
• Ask legal advice from a Medicaid fraud attorney. And you’d rather do it as soon as possible. An experienced lawyer can help you reach an administrative settlement for your case or even dismiss it.