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.
First of all, it is necessary to figure out the difference between Medicare fraud and Medicare abuse and what constitutes each of them.
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:
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:
Compliance with the standards of the national healthcare programs are regulated by the following laws:
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.
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.
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:
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