Medicaid Fraud and Federal Healthcare Fraud cases in general are proactively prosecuted by the U.S. Attorney’s Offices access the country. While there is no specific criminal statute that applies to Medicaid Fraud, these charges are frequently prosecuted on the federal level under:

  • Wire Fraud,
  • Mail Fraud,
  • Healthcare Fraud
  • False Claims Act,
  • Anti-Kickback Statute, AND
  • Stark Law.

Wire Fraud

The federal wire fraud statute, codified in 18 U.S.C. §1343, is frequently used in Medicaid prosecutions. Wire fraud charges apply in situations where individuals having devised or intending to devise “any scheme or artifice to defraud, or for obtaining money or property by means of false or fraudulent pretenses, representations, or promises, transmits or causes to be transmitted by means of wire, radio, or television communication in interstate or foreign commerce, any writings, signs, signals, pictures, or sounds for the purpose of executing such scheme or artifice shall be fined under this title or imprisoned.”

Penalties and Sentencing for Wire Fraud

Sentencing for federal Wire Fraud charges is controlled by United States Sentencing Guidelines. This charge is punishable by up to 20 years imprisonment and/or a fine of up to $250,000. The exact sentence will be determined by the sentencing judge. However, the loss amount, or money wrongfully obtained from the scheme is a significant factor in the judge devising the sentence.

Mail Fraud

Mail fraud is another federal charge that is frequently used to prosecute federal Medicaid Fraud charges. The federal Mail Fraud statute is codified in 18 U.S.C. §1341. This statute is analogous to the Wire Fraud statute, except it requires the use of a post office, authorized depository for mail matter, or any private or commercial interstate carrier. Medicaid fraud cases are prosecuted under the Mail Fraud statute, when the Government can prove that bills were fraudulently submitted or payment was made by Medicaid through the mail i.e. mailing of the check for payment.

Penalties and Sentencing for Mail Fraud Charges

Sentencing for federal Mail Fraud charges is controlled by United States Sentencing Guidelines. This charge is punishable by up to 20 years imprisonment and/or a fine of up to $250,000. The exact sentence imposed is solely up to the sentencing judge.

Healthcare Fraud

Medicaid Fraud charges can also be prosecuted under the federal Healthcare Fraud statute, which is codified in 18 U.S.C. 1347. The elements of healthcare fraud are:

(a) Knowing and willful execution, or attempt to execute, a scheme or artifice—

(1) to defraud any health care benefit program; or

(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, 

(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.

Sentencing and Penalties for Healthcare Fraud

Healthcare Fraud is punishable by up to 10 years in prison. However, if death or serious physical injury occurs, this charge is punishable by up to 20 years in prison. The exact sentence, however, will be determined by the sentencing judge on the Medicaid fraud case.

False Claims Act

False Claims is a federal statute that was passed in 1863, which is designed to protect the federal government from individuals and companies submitting false claims for payment and reimbursement. The False Claims Act is codified in 31 U.S.C. Sections 3729-3733. Under the False Claims Act, it is a federal offense to submit any “false or fraudulent” claim to the U.S. Government. This applies to overbilling or submitting false claims to Medicaid.

Penalties and Sentencing for Violations of False Claims Act

False Claims Act is punishable by both civil and criminal penalties, thus making it a powerful statute to levy Medicaid Fraud charges.

Civil Penalties Under the False Claims Act

Medicaid Fraud under the False Claims Act is punishable by these civil penalties:

  • Fines of up to 23,331 per false claim (as of 2020),
  • Treble damages (three times the Government’s actual losses),
  • Recoupment of overbilled amounts,
  • Reimbursement to U.S. Government of costs and expenses associated with bringing the action,
  • Pre-payment review and non-payment of future claims,
  • Exclusion from Medicaid and other health care benefit programs, AND
  • Potential adverse consequences to your professional license.

Criminal Penalties Under the False Claims Act

Medicaid Fraud under The False Claims Act is punishable by these criminal penalties.

  • Up to 5 years in prison for each violation,
  • Up to $250,000 in fines.

Anti-Kickback Statute

The federal Anti-Kickback Statute is codified in 42 U.S.C. Section 1320a-7b(b). This charge prohibits offering, soliciting, paying or receiving any form of compensation in order to induce or reward referrals that are reimbursed by Medicaid.

Sentencing and Penalties for Violations of Anti-Kickback Statute

Civil Penalties Under the Anti-Kickback Statute

  • False Claims Act liability
  • Recoupments
  • Treble damages
  • Civil monetary penalties (CMP)
  • Program exclusion

Criminal Penalties Under the Anti-Kickback Statute

  • Fines of up to nearly $75,000 per violation
  • Up to five years of federal incarceration per violation

Stark Law

The Stark Law is a civil statute, codified in 42 U.S.C. Section 1395nn, that prohibits medical professionals from making referrals to related entities for health services reimbursed through Medicaid. Under the Stark Law, civil penalties are imposed on both the referrers as well as the entities receiving prohibited referrals.

Penalties for Violations of Stark Law

Violations of Stark Law do not carry any criminal penalties. With that being said, criminal penalties may be imposed on charges that are related to violations of the Stark Law. Civil penalties that can be imposed on violations of the Stark Law:

  • Recoupments,
  • Treble damages,
  • Civil monetary penalties
  • Potential exclusion from participation in Medicaid Programs.

Frequently Asked Questions Regarding Medicaid Fraud

1. What are Examples of Conduct that Constitutes Medicaid Fraud?

Generally speaking, Medicaid Fraud applies to a large number of schemes. For example, the following conduct has been prosecuted as Medicaid Fraud:

  • Billing for services that were never performed,
  • Upcoding for services performed,
  • Billing for unbundled services,
  • Billing for equipment that was never provided,
  • Accepting kickbacks for patient referrals,
  • Ordering unnecessary tests.

2. Is Medicaid Fraud Prosecuted on the Federal or on the State Level?

Medicaid Fraud is usually prosecuted on the federal level. However, New York State has its own Healthcare Fraud statute that is used to prosecute Medicaid Fraud.

3. What is the Statute of Limitations for Medicaid Fraud?

Generally, the criminal statute of limitations on Medicaid Fraud cases is five years. The civil statute of limitations on Medicaid Fraud cases is six years. Importantly, the statute of limitations does not begin to run until the criminal conduct ends or the individual withdraws from the Medicaid Fraud conspiracy. When assessing your statute of limitations defense, it is important to consult a criminal defense attorney.

Contact Top Rated Medicaid Criminal Defense Attorneys

If you or your loved one are under investigation, or have been arrested for Medicaid Fraud, you need top rated and experienced criminal counsel. These Medicaid fraud investigations frequently span months, if not years. Therefore, it is essential that your counsel has the necessary expertise and time to dedicate to your case. Read our testimonials to find out what our clients say about our service and contact us today to schedule your initial consultation.