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What Is Medicare Fraud And Abuse

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Conspiracy Mail Fraud Wire Fraud: Misdemeanor Or Felony

Medicare & You: Preventing Medicare Fraud

In addition to the underlying fraud charges, a defendant charged with Medicare fraud may face several other criminal charges. An overzealous prosecutor could charge the defendant with conspiracy, mail fraud, or wire fraud, depending upon the means used to perpetrate the alleged fraud.

Mail fraud and wire fraud are both felonies with penalties ranging up to 20 years in prison for each count . Mail and wire fraud are federal crimes, chargeable when an underlying fraud scheme was committed by way of the mail or interstate wire communications.

A defendant may also be charged with conspiracy. Conspiracy is chargeable under both state and federal law. To be guilty of conspiracy, the defendant must have entered into an agreement with at least one other person to commit a crime and performed at least one overt act in furtherance of that conspiracy .

Under California law, conspiracy can be charged as a misdemeanor or a felony, typically based on the severity of the underlying criminal activity and the nature of the defendants conduct and participation in that conspiracy.

Conspiracy against the United States is a federal felony, punishable by up to five years in prison. If the underlying crime was a misdemeanor, however, then the punishment cannot exceed the maximum punishment that the misdemeanor would have carried.

What To Look For

Common signs of Medicare fraud and abuse include getting:

  • Billed for services or equipment you didn’t receive
  • Promised cheaper services or testing
  • Pressured to have unnecessary services performed or to receive unnecessary supplies
  • Charged a copay when you dont owe one, or getting a copay waiver when you dont qualify for one
  • Lied to about the services or benefits you will receive under your plan

Medicare Fraud Vs Abuse

When it comes to Medicare fraud, it is important to differentiate the practice from improper payments. Examples of Medicare fraud include billing a patient for services that were not actually provided, billing a patient for an appointment they did not actually attend, billing for unnecessary services, or using the wrong billing code to increase costs.

While similar to fraud, Medicare abuse usually entails taking actions that cost the program more than necessary, while also decreasing the quality of care received by the patient. Compliance officials determine abuse by comparing the quality of the care provided to the standards all other doctors and medical providers must follow.

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How Can Medicare Fraud And Abuse Be Prevented

Its very important to keep your Medicare number private and secure. You need to keep all your medical records protected. If you notice a doctor trying to provide services you dont need, say something and report the issue to Medicare.

When you get the NOT A BILL letter that goes over all the services youve received from your healthcare visit, its important to review that. Make sure everything on the paper lines up with the services that were provided.

Many people just throw this paper away, leaving scammers to keep scamming the system.

What To Do About Medicare Abuse

Preventing Medicare Fraud

If you find an error on your MSN or EOB, there are steps you can take. The first thing you will want to do is reach out to your healthcare providers office. It could be a simple billing issue that can be easily corrected.

If this does not correct the problem, or you find something more suspicious , you will want to take action and report this to the proper authorities so they can open an investigation.

For Original Medicare:

For Medicare Advantage and/or Part D plans:

  • Medicare Drug Integrity Contractor : 1-877-7SAFERX

You will want to have the appropriate information on hand when reaching out. This will include your name, Medicare number, claim information, and any billing discrepancies between the claim and your records.

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Medicare Fraud Strike Task Force Charges

  • In July 2010, the Medicare Fraud Strike Task Force announced its largest fraud discovery ever when charging 94 people nationwide for allegedly submitting a total of $251 million in fraudulent Medicare claims. The 94 people charged included doctors, medical assistants, and health care firm owners, and 36 of them have been found and arrested. Charges were filed in Baton Rouge , Miami Brooklyn, , Detroit and Houston . By value, nearly half of the false claims were made in Miami-Dade County, Florida. The Medicare claims covered HIV treatment, medical equipment, physical therapy and other unnecessary services or items, or those not provided.
  • In October 2010, network of Armenian gangsters and their associates used phantom healthcare clinics and other means to try to cheat Medicare out of $163 million, the largest fraud by one criminal enterprise in the program’s history according to U.S. authorities The operation was under the protection of an Armenian crime boss, known in the former Soviet Union as a “vor,” Armen Kazarian. Of the 73 individuals indicted for this scheme, more than 50 people were arrested on October 13, 2010 in New York, California, New Mexico, Ohio and Georgia.

Civil Monetary Penalties Law

OIG may seek civil monetary penalties and sometimes exclusion for a wide variety of conduct and is authorized to seek different amounts of penalties and assessments based on the type of violation at issue. Penalties range from $10,000 to $50,000 per violation. Some examples of CMPL violations include:

  • presenting a claim that the person knows or should know is for an item or service that was not provided as claimed or is false or fraudulent
  • presenting a claim that the person knows or should know is for an item or service for which payment may not be made
  • violating the AKS

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Tips For Avoiding Health Care Fraud

  • Protect your health insurance information. Treat it like a credit card. Don’t give it to others to use, and be mindful when using it at the doctors office or pharmacy.
  • Beware of free services. If you’re asked to provide your health insurance information for a free service, the service is probably not free and could be fraudulently charged to your insurance company.
  • Check your explanation of benefits regularly. Make sure the dates, locations, and services billed match what you actually received. If theres a concern, contact your health insurance provider.

Criminal Medicare Fraud: Civil Liability Misdemeanor Or Felony

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Medicare fraud is a broad-brush term that encompasses a variety of conduct. Medicare fraud is chargeable when a defendant obtains money from Medicare under false pretenses. Medicare fraud can involve billing fraud or violation of several other statutes, including the Stark Law , the Anti-Kickback Statute, the False Claims Act, the Social Security Act, or the U.S. Criminal Code.

Perpetrators of Medicare fraud can face civil or criminal sanctions. Civil liability can lead to heavy fines, exclusion from Medicare, and treble damages. Criminal fraud can lead to prison terms. Criminal fraud typically requires a higher level of mental culpability and carries a higher burden of proof .

In California, defrauding Medi-Cal or committing other forms of healthcare fraud can be charged as a misdemeanor or a felony, depending on the circumstances. Factors affecting the charging decision include the amount defrauded, the means used to do so, and the nature of the defendants specific conduct.

Federal Medicare fraud can be prosecuted as health care fraud under 18 U.S.C. § 1347, which is chargeable as a felony and punishable by up to 20 years in prison. Federal Medicare fraud may be charged as major fraud against the United States, a felony, or as a conspiracy, mail fraud, or wire fraud, as discussed below.

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Tips To Prevent Medicare Fraud Or Abuse

Here are some things you can do to stop fraud and abuse before it starts:

  • Protect your identity Never share your Social Security number, bank account numbers or Medicare number with someone you dont trust.
  • Keep your medical records safe Dont allow anyone except your doctor or Medicare provider to review your medical records.
  • Ask questions Call your doctor, Medicare provider or insurance company and ask them about any mistakes you find.
  • Know your rights As a person on Medicare, you have certain rights and protections, opens new window to help protect you.

What Is Medicare Abuse

Medicare abuse generally involves the illegal practice of falsifying Medicare claims to receive higher financial compensation.

Medicare fraud can come in many forms, such as billing for excess services or cancelled appointments. It can happen in any part of Medicares program, from original Medicare to Medicare add-ons and Medicare Advantage plans.

Common instances of Medicare fraud may include:

  • billing for services above and beyond those performed
  • billing for services that were not performed at all
  • billing for cancelled or no-show appointments
  • billing for supplies that were not delivered or provided
  • ordering unnecessary medical services or tests for patients
  • ordering unnecessary medical supplies for patients
  • receiving kickbacks and incentives for patient referrals

Medicare fraud may also involve identity theft. This is when a persons Medicare information is stolen and used to submit fraudulent claims.

The National Health Care Anti-Fraud Association estimates that fraud in the healthcare industry costs the government and taxpayers tens of billions of dollars. And while theres no exact estimate of the magnitude of Medicare fraud, improper Medicare payments were estimated to be $52 billion in 2017 alone. Some of these cases were classified as Medicare fraud.

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Insurance Brokers Commit Fraud When They

  • Bribe, mislead or coerce a beneficiary to enroll into or switch plans just to make a commission even though the plan may not be the best choice for the beneficiary.
  • Enroll a beneficiary into a Medicare Advantage plan without the beneficiarys consent.
  • Make unsolicited phone calls, emails or home visits.

What Are The Impacts Of Medicare Fraud And Medicare Abuse

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Although Medicare fraud and Medicare abuse differ due to the factor of intent, both are problems that can cost billions of dollars every year. While inappropriate, sometimes, illegal claims are made to the Medicare system, and it results in everyday people losing their tax dollars. People who are on Medicare can end up suffering by being denied certain medical services they need as a result.

Most doctors and other medical professionals strive to provide the best quality care to their patients. Often, when theres a problem involving Medicare, it could simply be an honest mistake rather than healthcare fraud. There is a longstanding relationship involving trust between healthcare professionals and Medicare. Patients rely on Medicare for all their medical needs.

Medicare fraud and abuse are serious. If youve been accused, protect your rights.

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Examples Of Medicare And Medicaid Fraud

Charging the government for medically unnecessary drugs, procedures, or tests in order to profit is one example of healthcare fraud. In 2022, for example, a Florida man who owned and operated several telemedicine platforms was sentenced to 14 years in prison for fraud that cost Medicare more than $20 million dollars. He marketed and prescribed medically unnecessary genetic tests to Medicare beneficiaries in exchange for kickbacks and bribes. The accused knew that the genetic laboratories involved would bill Medicare for medically unnecessary goods and services.

Another way of committing fraud is to impersonate a licensed provider. For example, in 2022, a Texas woman was accused of using her ex-husbandâs provider number to submit fraudulent claims to Medicaid for counseling services that were never provided, receiving more than $600,000 in fraudulent claims.

What Is Fraud Waste And Abuse

Fraud is when someone Knowingly solicits, receives, offers, or pays remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs.

Waste is the overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs.

Abuse describes practices that may directly or indirectly result in unnecessary costs to the Medicare Program. Abuse includes any practice that does not provide patients with medically necessary services or meet professionally recognized standards of care.

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Penalties For Medicare Fraud And Abuse

Several laws are in place to protect the government against these practices. Anyone committing Medicare fraud and abuse can face serious consequences ranging from imprisonment to financial penalties. Not only could they be asked to repay any claims, in some cases they could pay as much as three times the damages.

Someone found guilty of Medicare fraud could be excluded from participating in Medicare and other federal programs in the future. Medical licenses could also be suspended or revoked.

As of September 2020, the Medicare Fraud Task Force reported 3,075 indictments accounting for $3.82 billion. In May 2021, the Department of Justice took down a COVID-19 and telehealth scheme that targeted Medicare beneficiaries for $143 million.

Although it was not limited to Medicare, the DOJ also charged 138 healthcare professionals, 42 of them doctors, for $1.4 billion in healthcare fraud in September 2021.

How To Prevent Them At Your Practice

Medicare Fraud, Waste & Abuse

Fortunately, there are lots of steps your clinic can take to avoid fraud and abuse and remain compliant with all pertinent guidelines. Having a compliance professional within your organization ensures that any oversights or issues become apparent immediately. Your compliance professionals should also work from written documentation that clearly defines appropriate procedures.

Employee training is another crucial component of avoiding fraud and abuse. Make sure your staff is up-to-date on all rules and regulations. Regular monitoring and auditing of your prevention system should also take place, which will ensure it continues to offer the same protection.

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Understanding Medicare And Medicaid Fraud

Medicare and Medicaid fraud can be committed by medical professionals, healthcare facilities, patients or program participants, and outside parties who may pretend to be one of these parties.

There are many types of Medicare and Medicaid fraud. Common examples include:

  • Billing for services that weren’t provided, in the form of phantom billing and upcoding.
  • Performing unnecessary tests or giving unnecessary referrals, which is known as ping-ponging.
  • Charging separately for services that are usually charged at a package rate, known as unbundling.
  • Abusing or mistreating patients.
  • Providing benefits to which the patients or participants who receive them are not eligible, by means of fraud or deception, or by not correctly reporting assets, income, or other financial information.
  • Filing claims for reimbursement to which the claimant is not legitimately entitled.
  • Committing identity theft to receive services by pretending to be someone who is eligible to receive services.

Learn How To Recognize Report And Protect Yourself From Health Care Fraud And Abuse

Health care fraud and abuse refers to deceptive practices in the health industry that lead to undeserved profit. These schemes cost the nation billions of dollars each year and result in higher health insurance premiums and out-of-pocket expenses for consumers.

Health care fraud is a deliberate deception or misrepresentation of services that results in an unauthorized reimbursement.

Health care abuse refers to practices that are inconsistent with accepted medical, business, or fiscal practices.

These practices can take many forms, the most common including:

The Consumer Protection Division of the Office of the Attorney General aims to help educate consumers on how to recognize fraud and abuse and how to file a complaint with the appropriate agency.

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What You Can Review

Double-check all of your Medicare documents for errors:

  • Compare the dates, services and charges on your calendar with the statements you get from Medicare. These include the Medicare Summary Notice , opens new window if you have Original Medicare , or similar statements if you’re in a Medicare Advantage plan.
  • Review all receipts and statements from providers for mistakes.
  • Check your claims earlythe sooner you see and report errors, the sooner you can help stop fraud.

What Is The Difference Between Medicare Abuse And Medicare Fraud

How To Prevent Medicare Fraud

Medicare fraud is when a person deliberately seeks financial gain when they know the money does not belong to them. Fraud can also occur when a person tries to obtain money or other compensation for services or items for which they get Medicare reimbursement, or when they make banned referrals.

Individuals or groups can both commit Medicare fraud. The people involved, either indirectly or directly, can include doctors, other health providers, suppliers, and Medicare beneficiaries.

Medicare abuse and fraud can expose doctors and other health providers to civil and criminal liability.

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