7 Common Allegations in Medicare Fraud Investigations

Many Medicare fraud investigations stem from the federal government’s analysis of billing data and its discovery of reimbursement requests that appear to reflect intentional coding violations. Billing at a higher reimbursement rate than allowed (“upcoding”), billing separately for related services (“unbundling”), and other forms of coding fraud can all lead to the penalties listed above.

Many providers are surprised to learn that even honest coding mistakes resulting from human error can lead to allegations of Medicare fraud. While intent is required in order to prove criminal liability, under various federal statutes, the government can pursue civil remedies even for unintentional billing violations.

Medicare reimbursement is available only for services and supplies that are medically-necessary. Increasingly, the Centers for Medicare and Medicaid Services (CMS) and other federal authorities are questioning the medical necessity of billed services – and seeking recoupments and other penalties when they determine that services were not medically required.

Billing for services or supplies that were not actually provided is a clear form of Medicare fraud; however, cases of alleged “phantom billing” are not always as straightforward as they may initially seem. If you are under investigation for billing for phantom supplies or services in the Miami area, you need to speak with a health care fraud defense lawyer as soon as possible.

Falsifying patient records, fabricating or misrepresenting test results, and submitting fraudulent physician certifications are common forms of Medicare fraud as well. To avoid (or defend against) these types of allegations, providers should implement comprehensive compliance programs and maintain clear and organized records of all diagnoses and services rendered.

Prescription drug fraud, including prescription drug diversion, is also a form of Medicare fraud that is high on the federal government’s list of law enforcement priorities. Physicians, pharmacists and other providers accused of selling prescriptions or otherwise violating federal controlled substances laws must take an aggressive approach to defending themselves in order to avoid (or mitigate) civil or criminal liability.

The federal Anti-Kickback Statute, the Stark Law, and various other federal health care laws prohibit the use of Medicare funds to pay compensation for patient referrals. These statutes are extremely broad in scope, but they also contain numerous safe harbors and exceptions, and defending against bribe, kickback and self-referral allegations requires a thorough understanding of the laws and regulations that apply.