Millions of Americans count on Medicare and Medicaid to help them pay for the healthcare they need. These programs involve considerable amounts of money, which makes them a target for fraud. Because of the intricacies of these programs, it’s often possible that someone will be accused of fraud when they weren’t actually committing a crime.
Medicare and Medicaid fraud happens when someone knowingly tries to get money from these programs through false or dishonest claims. Some common examples of fraud include:
- Billing for medical services that were never provided
- Charging for more expensive services than were actually performed, which is known as upcoding
- Performing unnecessary medical procedures just to bill the programs
- Submitting duplicate claims for the same service
- Providing kickbacks to doctors or patients in exchange for referrals or services
Fraud can be committed by healthcare providers, employees working in medical offices, patients, suppliers of medical equipment or anyone involved in billing or services tied to these programs.
What defenses are possible?
Medicare and Medicaid fraud are serious charges that can result in steep fines, repayment of funds, exclusion from government programs and even prison time. There are several possible defenses that might apply, depending on the facts of the case:
- Lack of intent: Fraud requires intent. A billing error, clerical mistake, or misunderstanding of complex rules might be evidence of negligence, but not necessarily fraud.
- Mistaken identity: In some cases, someone else may have committed the fraud using another person’s credentials or identity.
- Compliance with regulations: Healthcare billing and coding rules are complex. A provider may show they made reasonable efforts to comply with laws and relied on professional billing services, suggesting no intent to defraud.
- Statute of limitations: There’s a time limit for bringing fraud charges. If too much time has passed since the alleged fraud occurred, a defense may be raised under the statute of limitations.
These cases can be complex, so it’s critical that anyone who’s facing these charges ensure they understand their defense strategy options. It may be beneficial for them to work with someone familiar with these cases.