What is Medicare Fraud?

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Medicare Fraud is a type of healthcare fraud that occurs when someone knowingly deceives Medicare to receive payment they are not entitled to. Medicare Fraud occurs both when the provider:

  • Seeks payment for services not provided, OR
  • Seeks higher payment than what they are entitled to.

Doctors, Medicare beneficiaries and other providers can be charged with Medicare Fraud. The following are common examples of conduct that is prosecuted as Medicare Fraud:

Medicare Fraud by Providers or Recruiters

  • Billing Medicare for services the patient never received,
  • Billing Medicare for services that are different from the ones patient received,
  • Continuing to bill Medicare for rented medical equipment after the provider returned it,
  • Performing services that are not medically necessary in order to charge Medicare for more services,
  • Billing non-covered services as covered services,
  • Soliciting or receiving kickbacks.

Medicare Fraud by Patients

  • Using another patient’s Medicare card to obtain medical benefits.
  • Receiving kickbacks for agreeing to undergo unnecessary medical procedures or accepting medical equipment that is not needed.

As indicated in the above examples, in order to be criminally charged with Medicare Fraud, the conduct needs to be pervasive. While making a billing mistake will not subject you to Medicare Fraud charges, abuse of the Medicare system for personal gain will.

What Medical Programs Are Involved in Healthcare Fraud?

Healthcare Fraud usually involves fraud against private insurance companies as well as the following government programs:

  • Medicare, which is a federal healthcare program providing insurance and healthcare services to individuals ages 65 and over, and those with certain disabilities and conditions;
  • Medicaid, which is a joint federal-state healthcare program providing insurance and healthcare services to low-income individuals, including those with disabilities;
  • TRICARE, which is a military healthcare program providing healthcare benefits and services to uniformed service members, retirees, and their families.

What Constitutes Medicare Fraud?

Medicare Fraud applies to a variety of schemes. Some examples of Medicare Fraud are:

Filing False Claims

Physicians and other medical service providers can be prosecuted for Medicare Fraud for submitting false medical claims, engaging in fraudulent medical billing or creating false records in order to obtain payment from Medicare.

Giving or Taking Kickbacks

Medical professionals and recruiters can be prosecuted for Medicare Fraud under the Anti-Kickback statute, which is codified in 42 U.S. Code § 1320a–7b. Under the Anti-Kickback statute, the providers are prohibited from offering or giving anything of value to a person in return for referrals or anything else that will generate business. Anything of value has a broad definition and includes money, gifts, products, vacations or items given with the expectation that they will generate business or increase referrals.

Phantom Billing and Double Billing

Phantom Billing is the most common form of Medicare Fraud and involves submitting bills for services not provided. This may involve patients who were never treated by the provider, tests that were never administered or services that were never performed.

Double billing involves submitting requests for payment for the same service to multiple parties- Medicare, insurance company and the patient. This practice may also involve fraudulently billing a party for multiple dates of service, when the service was only provided once.

Falsification of Cost Reports and Falsification of Patient Records

These fraudulent schemes involves classifying personal expenses as professional expenses related to the treatment of patients in order to obtain a tax break. Federal prosecutors have brought criminal healthcare charges relating to billing for new cars, home renovations or other personal costs.


Under the Start Act, codified in 42 USC § 1395nn, healthcare providers are prohibited from offering referrals to facilities in which they have a personal interest in. This also includes making referrals to facilities in which their immediate family member has a financial interest.

Who Investigates Medicare Fraud Cases?

Numerous agencies investigate Medicare fraud and healthcare fraud in general. These agencies include:

  • Department of Justice’s Healthcare Fraud Strike Force,
  • Health and Human Services Office of Inspector General (HHS-OIG),
  • Federal Bureau of Investigation (FBI),
  • Drug Enforcement Administration (DEA),
  • Regional Prescription Opioid Taskforces,
  • State Medicaid Fraud Control Units,
  • Local Medicaid Fraud Control Units.

What Statutes Are Used to Prosecute Medicare Fraud?

Several federal statutes are used to charge Medicare or Healthcare Fraud depending on the fact pattern of conduct alleged. Usually, the charge of healthcare fraud conspiracy is included in the indictment. Simply put, a conspiracy is an agreement between two or more people to engage in healthcare fraud. Additionally, it is very common for federal healthcare fraud indictments to contain a money laundering charge. Money laundering charges involve the concealment of the original source of funds from illegal activity.

Here are some of the federal statutes charged in a common Medicare Fraud Indictment.

  • Healthcare Fraud in violation of 18 U.S.C. 1347,
  • Healthcare Fraud Conspiracy in violation of 18 U.S.C. 1349,
  • Wire Fraud in violation of 18 U.S.C. 1343,
  • Racketeering in violation of 18 U.S.C. 1961,
  • Money Laundering in violation of 18 U.S.C. 1956,
  • Drug Trafficking in violation of 21 U.S.C. 841(a),
  • Anti-Kickback Statute in violation of 42 U.S.C. 1320a-7b, AND
  • Conspiracy in violation of 18 U.S.C. 371 .

What are the Elements of Healthcare Fraud?

In order to be convicted of healthcare fraud or Medicare Fraud, the government must prove that the Defendant:

  • Knowingly and willfully
  • Devised a scheme or artifice
  • To defraud a healthcare benefit program, AND
  • That the scheme was executed

In order to convict someone for committing Medicare Fraud, the U.S. Attorney’s Office must prove each of those elements to the jury beyond a reasonable doubt. Once again, just because someone is violating billing requirements of Medicare, does not necessarily mean that they are guilty of Medicare fraud. It is essential to retain an experienced Medicare Fraud attorney to fully investigate whether the Government is able to meet its burden of proof on each and every element of this criminal statute.

What Are the Penalties for Medicare Fraud?

Medicare Fraud is punishable by both civil and criminal penalties, which are explained in greater detail below. Additionally a conviction for Medicare Fraud may result in licensing implications for the providers – such as the loss or suspension of the medical license.

Civil Penalties for Medicare Fraud

Civil penalties for Medicare Fraud can include fines, recoupments and other financial penalties. The amounts that are recouped through civil penalties are three times the loss amount of the improperly paid Medicare benefits. Frequently, these civil penalties can add up to millions of dollars. Additionally, as part of the civil penalties, providers may be excluded from participating in Medicare programs.

Criminal Penalties for Medicare Fraud

Medicare Fraud is frequently punishable by jail time. Healthcare Fraud under 18 U.S.C. § 1347 is punishable by up to 10 years in prison. If the violation of the Healthcare Fraud involves serious bodily injury, this charge is punishable by up to 20 years in prison. However, if death results as part of the Healthcare Fraud, then Medicare Fraud is punishable by up to life in prison.

How Do I Know that I am Under Investigation for Healthcare Fraud?

There are a number of ways that you can find out that you are under investigation for Healthcare Fraud. Specifically,

  • Search Warrant Execution on your home or place of business,
  • Grand Jury Target, Subject or Witness letter notifying you that you are the target, subject, or witness of a federal investigation,
  • Grand Jury Subpoena for production of your records or testimony before the Grand Jury,
  • Medicare Suspension based on “credible and suspected allegations of fraud”
  • Audits by Medicare, Medicaid, or private insurance companies, especially if they are increasing in number and frequency.

If any of these things happen to you, you need to contact Healthcare Fraud Attorney for assistance. Time is of the essence with these type of cases, so do not delay scheduling your initial consultation.

Contact Top Rated Medicare Fraud Attorneys

If you or your loved one has been charged with or suspect you are under investigation for committing Medicare Fraud, you need top rated Medicare Fraud Defense Attorneys. We have represented numerous individuals charged with Medicare and other Healthcare Fraud. Contact us today to start developing your defense strategy.