What are Some Common Examples of Medicare Fraud?

Following the Department of Justice’s national $900 million Medicare fraud takedown earlier this year, the Department of Justice, the Medicare Fraud Strike Force and other federal law enforcement authorities are continuing to aggressively pursue cases of suspected Medicare fraud. Medical providers and others in the healthcare industry throughout North Carolina are increasingly at risk for becoming targets in federal investigations, with civil and criminal prosecutions having the potential to lead to huge financial liabilities, loss of eligibility for Medicare reimbursement and even time behind bars.

But, what exactly is Medicare fraud? More importantly, what can practitioners in North Carolina do to help protect themselves from facing federal charges?

Common Allegations in Medicare Fraud Investigations

“Medicare fraud” is a broad term that encompasses violations of a number of different federal statutes. Some of the most common examples of Medicare fraud allegations include:

• Billing for Medically-Unnecessary Supplies or Services – Physicians will often face Medicare fraud charges based upon allegations of billing Medicare for services or medical supplies that were not medically necessary.
• Billing for Supplies or Services Not Provided – “Phantom billing” is the practice of seeking Medicare reimbursement for supplies or services that were never actually provided to a patient.
• Falsifying Patient Records – Submitting falsified patient records in connection with a reimbursement claim is another form of Medicare fraud.
• Making Prohibited Referrals – Under the Stark Law, physicians are prohibited from making certain referrals to companies with which they have a financial relationship. Stark Law violations are commonly charged as a form of Medicare fraud.
• Offering or Accepting Illegal Kickbacks – The federal Anti-Kickback Statute makes it illegal for physicians, pharmaceutical companies and others to make certain payments and provide other forms of compensation in exchange for recommendations or referrals.
• Unbundling Services – Under Medicare regulations, certain types of services must be billed at reduced, “bundled” rates. Unbundling services in order to claim higher reimbursement rates is a common form of Medicare fraud.
• Upcoding – Billing Medicare at a higher rate than is called for by the services performed or equipment supplied is a form of fraud known as “upcoding.”

The list goes on and on, and with the enormous complexity of the Medicare regulatory structure and billing system, it is not uncommon for physicians and others to face allegations when they have no knowledge of impropriety. Lack of knowledge can be a key defense in many Medicare fraud investigations, and you will want to promptly discuss your defense options with an experienced attorney.

Protecting Yourself (and Your Practice) in a Medicare Fraud Investigation

If you are facing a Medicare fraud investigation in North Carolina, there are several steps you need to try to take right away. Your goal should be to prevent the investigation from leading to civil or criminal charges, and the best way to do this is to hire an attorney to intervene in the investigation as soon as possible. Your attorney will be able to:

• Make contact with the investigators and prosecutors assigned to your case
• Determine the specific allegations against you
• Determine whether the investigation is civil or criminal
• Help you avoid unnecessarily disclosing information
• Help you address any practices that may have triggered the investigation
• Build a comprehensive defense strategy focused on minimizing the consequences of the investigation

Contact the Raleigh Criminal Defense Attorneys at Cheshire Parker Schneider & Bryan, PLLC

If you would like to speak with an attorney about your Medicare fraud investigation in confidence, contact the Raleigh, NC law offices of Cheshire Parker Schneider & Bryan, PLLC. To schedule an appointment as soon as possible, call (919) 833-3114 or contact us online today.