Fraud, waste, and abuse of Medicaid costs the state billions of dollars annually. Fraudulent practices not only increase Medicaid costs, they also increase potential harm to patients exposed to inappropriate procedures. According to the Government Accountability Office, in 2015, improper payments for non-covered services, or services that were billed but not provided amounted to $29 billion.
What is Medicaid Fraud?
Medicaid fraud refers to the misuse of Medicaid benefits and funds. This can be done by either the medical facility or the patient. There are a variety of actions that amount to Medicaid fraud.
For providers, typical fraudulent actions include:
- Falsifying claims: billing Medicaid for unnecessary equipment or services that have not been performed
- Phantom billing: billing Medicaid for a doctor’s visit that never took place
- Double billing: billing the patient and Medicaid
- Drug substitution: providing patients with a generic drug but billing Medicaid for a brand name drug
- Unbundling: billing services separately instead of combining them into one bill.
- Falsifying expense reports: compiling an expense report that features expenses that are not related to Medicaid claims
- Upbilling: billing for a service that is more expensive than the one delivered
For patients, typical fraudulent actions include:
- Giving a non-Medicaid participant their Medicaid card so they can get benefits
- Failing to report about their source of income
- Failing to return Medicaid benefits when a health insurance plan provides coverage
Laws Associated With Medicaid Fraud
According to OIG, the basic federal fraud and abuse laws that apply to physicians include: The False Claims Act; The Stark Law; Anti-Kickback Statute; and Civil Monetary Penalties Law.
False Claims Act:Submitting false statements knowingly or misrepresentation of facts for the purpose of obtaining federal health care payment that a health care provider should not receive amounts to false claims.
Stark Law: Making referrals for certain health services to an organization in which the practitioner’s immediate family owns or has a financial interest is covered by the Stark law. A typical example is a situation where a physician refers business to a clinic that his relative owns.
Anti-Kickback Statute:Knowingly paying, soliciting, or accepting any kind of payment to induce or reward referrals for products or services that are reimbursed by health care programs. A typical example is an arrangement which is not catered for by regulatory safe harbors and where money or other kinds of benefits are exchanged for referrals.
Civil Monetary Penalties Law: A typical example of civil monetary penalties is knowingly presenting a claim for a service or item that is false and fraudulent, or that is not covered by Medicare, or that violates the Anti-Kickback Statute.The government can subject a person or institution to a penalty of up to $50,000 for every false claim plus three times the amount claimed for every service or item.
How To Report Medicaid Fraud
Medicaid has an incentive reward program that aims to encourage people to report Medicaid fraud. According to medicare.gov, you stand to gain up to $1,000 if :
- You report a suspected case of Medicare fraud.
- The Medicare fraud is acknowledged as potential fraud by a recognized authority such as the Medicare Drug Integrity Contractor or a Zone Program Integrity Contractor.
- You are eligible for Medicaid benefits and are not part of the offense being reported.
- The organization or person who committed the fraud is not being investigated by law enforcement.
- Your report will result in the recovery of a minimum of $100.
Penalties for Medicaid Fraud
- Jail time: The defendant may face anywhere between five years and life imprisonment depending on the seriousness of the offense and whether it caused bodily injury or the death of a patient.
- Probation: The defendant may be subjected to probation. During the probation period, the defendant will be required to abide by all probationary requirements including employment standards and regularly attending probation meetings.
- Fines: Depending on the charges, a person facing fraud can be subjected to fines resulting to tens of thousands of dollars.
- Restitution: If the fraud led to the loss of funds for a patient or insurance company, they may be required to pay restitution to the victim as reimbursement for the money lost.
- Administrative sanctioning: If Medicaid fraud was caused by bad administration, the institution or practitioner will be subjected to administrative sanctions. The penalties include the revocation or suspension of the doctor’s license to participate in the Medicare program .
Summing It Up
Medicare fraud is a serious offense that can cause the perpetrator’s license to be revoked and subject them to huge fines and jail time. There are various laws that come to play in cases of Medicare fraud hence the need to involve a seasoned criminal defense attorney. If you or a loved one has been accused of Medicare fraud, it is advisable to seek legal counsel to have the charges reduced or withdrawn altogether.