Is Medicare Fraud A Felony?

Is Medicare fraud a felony?

Medicare fraud is a crime in which a person or company uses Medicare patients to defraud the Government. A crime is a felony in which the person convicted can be sentenced to more than one year in prison. Medicare fraud is a felony under the False Claims Act and can lead to up to five years in federal prison and a fine of up to $250,000.

Types of Medicare Fraud

Medicare fraud encompasses a wide range of deceptive practices aimed at exploiting the Medicare system for financial gain, ultimately at the expense of taxpayers and beneficiaries. One common example is billing for services or procedures that were never provided. Healthcare providers may submit claims for treatments, tests, or equipment that patients never received. Upcoding is a common example of Medicare fraud. Upcoding is when a provider intentionally assigns higher billing codes to procedures or services than what was actually performed, inflating the reimbursement amount. Similarly, unbundling is when a company bills separately for services that should be billed together at a lower rate.

A kickback is another form of Medicare fraud. A healthcare provider who receives financial incentives or rewards in exchange for referring patients for certain services, tests, or treatments has received a kickback. Kickbacks can lead to unnecessary or even harmful procedures performed on patients.

A Felony Medicare Fraud Conviction

A Florida durable medical equipment (DME) seller was recently convicted of felony Medicare fraud. The seller engaged in a scheme to defraud Medicare in three ways. First, he paid a half million dollars in kickbacks to purchase fraudulent DME orders, including orders in which the physician’s signatures were forged. These DME orders were for such equipment as braces for ankles, knees, elbows, wrists, and backs. Second, the seller resold some of the fraudulent orders to other DME suppliers to enable them to also defraud Medicare. Third, the seller bought five of his own fraudulent DME supply companies and used fraudulent DME orders to make more than $11 million in fraudulent Medicare claims.

Whisteblowers Are Protected And Entitled to Compensation

Whistleblowers play a crucial role in uncovering and combating these illicit activities. They can provide insider information about fraudulent practices within healthcare facilities, billing companies, or other organizations involved in Medicare billing. Whistleblowers often have firsthand knowledge of fraudulent activities and can provide essential evidence to authorities, leading to investigations and legal actions against perpetrators. The False Claims Act provides incentives and protections for whistleblowers, encouraging them to come forward with their information and ensuring they are shielded from retaliation. Whistleblowers can be rewarded a portion of the government’s recovery. Ultimately, whistleblowers serve as key allies in the fight against Medicare fraud, helping to protect the integrity of the healthcare system and ensure that taxpayer dollars are used appropriately to provide quality care to those in need.