Healthcare Fraud

What is Medicaid Fraud and Abuse?

What is Medicaid fraud? Medicaid fraud refers to when medical billing fraud is committed by a medical provider who knowingly tries to collect money that they’re not entitled to through the government Medicaid program. 

Benefit programs like Medicaid have protocols in place to audit their patient records for false statements, unnecessary treatments, or misused funds to ensure their program is being used appropriately. However, people can make mistakes or, in some cases, fraud may be committed without the other party knowing. 

The attorneys at Sellers Law Firm have put together this article to help you identify what constitutes Medicaid fraud, understand why you may have been charged, and explain our top defense strategies.

Types of Medicaid fraud

The answer to the question, “What is Medicaid fraud?” is especially complex because there are many different ways Medicaid fraud can be committed. Here are some of the most common Medicaid fraud examples that our attorneys see:

  • Medical identity theft: Using someone else’s Medicaid ID card to obtain medical goods, services, or funds
  • Lack of medical necessity: Billing for services that are unnecessary 
  • Upcoding: Billing for services at a higher price
  • Physician kickbacks and patient referrals: Making or accepting payments for referring, recommending, or arranging for the purchase of items paid for by Medicaid. This is also referred to as violating the Anti-Kickback Statute (AKS). 
  • Prescription drug fraud: Altering or writing unnecessary drug prescriptions, ie unlawful prescribing
  • Duplicate claims: Filing duplicate claims for one service provided
  • Other billing issues: Knowingly billing for an ineligible beneficiary to qualify for Medicaid, billing for services or items that were not provided, etc. 

Who can charge you with Medicaid fraud?

As mentioned earlier, government programs like Medicaid have a thorough process to check for any fraudulent behavior discussed above. If a healthcare provider or any other individual notices fraudulent behavior occurring, they can report you and your practice for violating the False Claims Act –– a type of whistleblower law that rewards those who expose types of fraud that results in a financial loss to the federal government (typically for healthcare programs like Medicaid). 

Once someone is reported, the Medicaid fraud control unit (MFCU) of your state will begin to investigate the claim. You can read more about MFCUs on the site for the National Association of Medicaid Fraud Units.  

What happens if you commit Medicaid fraud? 

False Claims Act penalties for each unlawful bill or request depend on the date of the violation and date of assessment, but can run up to $20,000+ per violation. However, if you are charged with violating the False Claims Act as a result of a Medicaid fraud claim against you, there is more on the line than just financial loss. 

You may face the following consequences if charged with Medicaid fraud:

  • Exclusion of your practice from Medicaid 
  • Loss of your medical license
  • Loss of DEA registration
  • Seizure of assets 
  • Restitution in addition to the aforementioned fines 

These consequences can have major repercussions on your career, your practice, and your reputation in the medical field. If you happen to receive notification that you are suspected of Medicaid fraud, contact a trusted healthcare fraud defense attorney immediately. You are within your rights to seek counsel from an attorney who is well-versed in Medicaid fraud cases to prevent any unnecessary investigation from the Department of Justice. 

Defenses against Medicaid fraud charges

In order to prove that you committed fraud against the Medicaid program, the prosecutor will have to prove the following under the False Claims Act (18 U.S.C. § 287): evidence that the defendant knowingly and purposefully 1) made a claim or statement to get the government to pay money on a claim and 2) that the claim or statement was false or fraudulent.

In response, your healthcare defense attorney can exhibit the following defenses depending on your case:

  • Lack of intent: The defendant did not knowingly or intentionally commit the fraudulent action(s).
  • Consent: A victim/patient accuses you of Medicaid fraud, but you have documentation that the person accusing you consented to the medical steps you took to treat them. 
  • Insufficient evidence: Whether you intended to commit healthcare fraud or not, there needs to be enough evidence to prove your intent beyond a reasonable doubt. If there’s not enough evidence, then there’s no case against you.
  • Voluntary disclosure: Reporting yourself to the agencies that oversee fraud can potentially lower your chances of receiving heavy fines, but it is still a risky choice. ALWAYS consult with an attorney before deciding whether or not to turn yourself in. 

Charged with Medicaid fraud? Contact a trusted attorney at Sellers Law Firm today

Now that we’ve answered the question, “What is Medicaid fraud?” you now have the knowledge necessary to take the right next steps if you are accused. 

When faced with a Medicaid fraud charge, who you hire to represent you is very important. There is a lot at stake: hefty fines, career ramifications, and more. An aggressive, trial-tested Dallas healthcare fraud lawyer from Sellers Law Firm will help you navigate the complex healthcare legal system and fight for your rights. 

You only get one shot to defend your practice and reputation. Contact our team online today or call us at 817-928-4222 to request a free consultation. 

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