All About Medicare Fraud Defense, from Our National Healthcare Criminal Lawyers

Image of pieces from the board game "scrabble" that spell out the word "law".

Everything You Need to Know About Medicare Fraud

Being a healthcare provider comes with an obligation to know and abide by Medicare’s rules.

Why? Because if you stray from the regulations in place — such as overbilling for services, charging for unprovided or unnecessary services, paying kickbacks for business — your practice will come under fire from federal Medicare fraud prosecutors.

Medicare fraud audits have the potential to evolve into criminal indictments, as well as civil recovery actions and state professional licensing complaints. You will be facing jail time, tens of thousands of dollars in overpayment demands, professional license suspension — even full revocation — and Medicare exclusion.

Our national healthcare fraud lawyers have everything you need to know about Medicare fraud investigations and audits — and why allegations should be taken seriously.

What is Healthcare Fraud?

Before learning about Medicare fraud, it is important to understand exactly what healthcare fraud entails. Healthcare fraud is a general term that applies to any scheme to commit fraud (a material misrepresentation designed and intended to result in financial gain) against a health care insurance program.

Healthcare fraud occurs when an individual knowingly submits a false statement or makes misrepresentations of fact, to obtain payment from a Federal health care program (Medicare, Medicaid, TriCare) for which no entitlement would otherwise exist.

When a claim is submitted for reimbursement for services that were either not medically necessary, not conducted, overbilled, or not allowable, the person and entity that caused the bill to be submitted can be prosecuted for fraud.

For Medicare fraud, that encompasses regulatory provisions, including the false claims act, Anti-Kickback Statute (federal and state specific), Stark Laws, and health care fraud statutes. 

Individuals who knowingly solicit, pay and/or accept remuneration to induce or reward patient referrals for services or supplies reimbursed by a federal health care program, may also be guilty of Medicare fraud, along with those making prohibited referrals for certain designated health services.

What Are Examples of Medicare Fraud?

    • Submitting false claims to CMS for payment
    • Billing for services or supplies not provided
    • Ghost patients: Submitting claims for services or supplies for a patient who does not exist or who the provider has no physician-patient relationship
    • Billing for services of such low quality that they are virtually worthless
    • Billing for durable medical equipment not legitimately prescribed by doctors
    • Unbundling: Billing for tests or treatment separately where there is an ICD-10 procedure code that covers/bundles the services
    • Up-Coding: Billing a higher code (CPT, ICD-10, E&M, HCPCS) than the service actually performed
    • Lack of medical necessity and overutilization: Performing additional treatments or tests which are not clinically necessary
    • Duplicate billing
    • Utilization of excluded providers: Submitting a claim on behalf of a provider that is ineligible to participate in Medicare and Medicaid
    • Non-Medicare participating providers billing patient more than 15% above the Medicare fee schedule, when a patient seeks reimbursement from Medicare
    • Making false statements on applications or contracts to participate in Medicare or Medicaid program
    • Providing false or misleading information expected to influence a decision to discharge a patient
    • Violating Medicare assignment provisions or the physician agreement

How Can Criminal Charges Apply in Medicare Fraud-Related Matters?

    • Attempt and Conspiracy to Commit: Any person who attempts or conspires to commit any offense under the healthcare fraud chapter is subject to the same penalties for the prescribed offense
    • Forfeiture: Property alleged to be constituting or derived from any proceeds of unlawful activity, directly or indirectly, or property used or intended to be used in any manner or part to commit or facilitate the alleged Medicare fraud, may be subject to forfeiture.
    • Money Laundering: Using proceeds from unlawful activity to promote or conceal that activity, or engage in transactions greater than $10,000 derived from the alleged claim.
    • Theft of Government Services: Can include billing for services performed by a provider, vendor or entity excluded from the Medicare program. This includes indirect billings made by an employer or practice group for services performed on a Medicare beneficiary by an employee who is excluded from the Medicare program.
    • Wire Fraud: The use of electronic communication or telephone in interstate communications made in furtherance of the alleged Medicare fraud.

What is the Requirement for Medicare Fraud Conviction?

What is the Requirement for Medicare Fraud Conviction?

Image showing some label something either Criminal Medicare fraud convictions require proof beyond a reasonable doubt that an individual knowingly and/or willfully submitted a false claim or engaged in kickbacks or healthcare fraud.

However, proof of actual knowledge or specific intent is not required for a conviction. A person can be convicted if they are found to have acted with deliberate ignorance or reckless disregard of the truth or falsity of the claim.

In some Medicare fraud cases, the ultimate issue is simply whether the individual acted knowingly and/or willfully. In other cases, the issues are much more complex.

For example, Medicare fraud allegations involving worthless services, medical necessity or overutilization present an additional question regarding the standard of care. The current government trend is to criminally charge physicians, pain management specialists, chiropractors, dentists, or other licensed medical professionals who allegedly prescribe/perform health care services that are not medically necessary.  

What Are the Possible Medicare Fraud Sanctions?

    • Restitution
    • Civil Monetary Penalties:
      • False Claims Act: Up to $21,563 per claim and a fine three time the number of damages sustained by the government as a result. Fine up to $250,000 if knowingly
      • Anti-Kickback Statute: Up to $50,000 per violation and a fine three times the amount of the kickback
      • Healthcare Fraud: Up to $250,000
      • Exclusion Statute: Up to $10,000 per item claimed while excluded and a fine three times the amount claimed
    • Jail Time:
      • Healthcare Fraud: Up to 10 years. Up to 20 years if bodily injury
      • Conspiracy to Commit Healthcare Fraud and Fraud: Up to 20 years
      • False Claims Act Convictions: Up to 5 years per occurrence. Up to Life if convicted of multiple counts
      • Money Laundering: Up to 10 years
      • Conspiracy to Commit Money Laundering: Up to 20 years
      • Wire Fraud: Up to 20 years
    • Other Sanctions and Collateral Consequences:

How Do Chapman Law Group’s National Medicare Fraud Defense Attorneys Stand Apart?

Our team of national Medicare fraud defense lawyers is dedicated to defending providers and suppliers suspected of Medicare fraud. They have significant experience in federal criminal defense, health care fraud investigations, regulatory compliance, audits, and civil and criminal Medicare fraud actions. In fact, our team includes a former Deputy Attorney General for the Medicaid Fraud Control Unit (MFCU) who prosecuted health care fraud cases.

We have built our team of national Medicare fraud defense lawyers to represent individuals across the U.S. who accused of fraud, through offices in Troy, Michigan; and Miami and Sarasota, Florida. Our clients include physicians, chiropractors, pharmacists, home health agencies, urgent care centers and behavioral health facilities.

In addition, we have an extensive network of experts who specialize in nearly every area of medicine — from board-certified pain management doctors to retired DEA drug diversion agents and private investigators — as well billing and coding.

Some of our current and recent Medicare fraud cases include:

    • Several home health agencies: Alleged to have committed Medicare Fraud for improper referrals, performing services outside the plan of care, not having proper authorizations, and not having proper re-certifications.
    • Behavioral services agencies: Alleged to have committed Medicare fraud for failure to use the proper CPT code resulting in allegations of fraudulent billing.
    • Compound pharmacies: We currently defend several individuals in multiple areas regarding compounding pharmacies. Generally, the allegation is that the pharmacy is “mining” patients through the use of a call center boiler room and the patients have no legitimate medical need for the compound, or the allegation is the compound serves no legitimate medical purpose and is no better than an over the counter medication or less expensive script.
    • Several physicians: Charged with receiving remuneration of referring patients and for approving plans of care that were not medically necessary.
    • Medical directors: Alleged to have committed Medicare fraud for receiving a salary or other payment, as well as referring patients to the program they currently work as the medical director.

When Medicare Fraud Allegations Put Your License, Reputation, and Livelihood at Stake, We Are Here to Protect You

Each lawyer in our healthcare defense practice at Chapman Law Group is uniquely suited to defend national Medicare fraud claims, as well as Qui Tam and whistleblower actions. Our knowledge of conditions of payment, conditions of participation, and 35 years of defending physicians accused of malpractice, give us the knowledge to understand and apply the standard of care, DRG’s, CPT’s, clinical practice guidelines and conditions of payment in the defense of our clients.

Our four national health care-based criminal defense law offices are in Detroit, MichiganMiami and Sarasota, Florida; and Los Angeles/Southern California. We serve healthcare providers across the U.S., from Chicago to Dallas, and from Seattle to Philadelphia. Contact us today for more information.

Need an Attorney? Contact us now!
or Call us at: 1 (877) 234-5911

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Got A Question?

Contact me now to schedule a consultation.

Other Practice Areas​

Health Care Fraud/
Criminal Defense

Related Case Results

Related Blog Posts

FREE Health Care Newsletter

Stay up to date on the latest news in health care law!

FREE eBook!

Click the link below to download our compliance eBook now!

Got A Question?

Contact me now to schedule a consultation.
Chapman Law Group Favicon

This website uses cookies to ensure you get the best experience on our website.

Send this to a friend