Are you under investigation for Medicare fraud? Several cases constitute healthcare fraud, and the incidents don’t only happen in the hospital setup. If you want to understand your case and situation, you must know the basics of Medicare fraud. A Medicare fraud lawyer comes in handy to take you through the basics and details of a Medicare fraud case.

Blog Posts & Articles

What is Medicare Fraud

Medicare fraud refers to scenarios where a healthcare professional submits false claims to a government healthcare program. Such incidents account for approximately $50 billion in claims annually. In most cases, the professionals end up being audited. Despite how much work they put in to cover up the mistakes, the truth always comes out.

Medicare fraud is governed by five statutes that you must understand for compliance purposes:

  • False Claims Act: This covers incidents where practitioners knowingly submit false statements to get federal health care payments which they are not entitled to.
  • Anti-Kickback Statute: This is the act of knowingly paying, soliciting, or accepting remuneration for referrals or services or items that are reimbursed by federal healthcare programs.
  • Stark Law: the law prohibits practitioners from making referrals to any entity in which they or their immediate family has a financial interest, ownership, or compensation arrangement.
  • Criminal Fraud Statute: a practitioner should not attempt or execute a scheme to defraud any health care benefit program to get money or property that belongs to the program through pretense.
  • Civil Monetary Penalties Law: the law prohibits a practitioner from presenting a claim for an item or service not provided as claimed. It’s also an offense to present a claim for services that Medicare doesn’t reimburse.

Investigations for Medicare fraud involve many parties, including

  • The Department of Health and Human Services
  • The Office of Inspector general
  • Medicaid Fraud Control Units
  • The FBI
  • The Department of Justice
  • State Medicaid Agencies

If you’re found guilty, criminal and civil punishment could both apply to you, depending on your specific case. The best way to know the kind of case you face is to sit down with a Medicare fraud lawyer, and they will help you prepare a strong defense.

Examples of Medicare Fraud

There are various reasons why you may be accused of Medicare fraud. These claims can vary in severity, ranging from minor infractions like clerical errors to significant errors like fraudulent billing.

Kickback Fraud

This is when you agree with pharmaceutical companies, laboratories, or clinics to offer them products, money, or services in exchange for client referrals. In other words, it’s illegal to provide an inducement to anyone in exchange for government healthcare. You also must not arrange for someone to get government healthcare or be on the receiving end of such an inducement to do any of those things.

Phantom Billing

Phantom billing is a common type of Medicare fraud that involves billing Medicare for treatment services you never offered. For example, a dentist may charge for full dental plates, whereas he only provided partial dentures. In some cases, service providers have been found guilty of creating phantom bills for patients who were no longer their clients. In worse cases, they continue to bill deceased patients.

Bundling and Unbundling Bills

Bundling and unbundling of bills refers to a billing procedure that covers medical procedures as part of others. While all types of procedures can include a lesser service within a service, billing should be done within the same package. However, sometimes healthcare providers unbundle the services and bills them separately. This helps them to get more money for each service, yet Medicare puts some of these services in the same group to make them more affordable for patients. Unbundling of bills is usually harder to detect, but a Medicare fraud lawyer can guide you in-depth.

Falsification of Patient Records and Cost Reports

Falsifying a patient’s medical records to receive payments for unnecessary treatments amounts to Medicare fraud. Asking for tests and examinations that aren’t required and convincing patients that they need surgeries and specialized treatment is an offense. It could also lead to the worsening of a patient’s condition.

You will also be investigated for fraud if you capture exaggerated or personal costs in a patient’s Medicare claims.

Double Billing

You can come under scrutiny and investigation if you bill your patients, Medicare, and the patient’s insurance company for the same treatment or medication.

Marketing Pharmaceuticals as Off-Label

Drugs approved by the Food and Drug Administration undergo vigorous testing for effectiveness and safety. The law prohibits doctors and pharmaceutical companies from promoting, marketing, prescribing, or selling medications for any purpose beyond what the FDA states.

Self-Referrals by Doctors

The law is clear that you should not refer patients to service providers or clinics where you have financial affiliations. For example, don’t refer your patients for specialized care in a healthcare company owned by your spouse, child, or an immediate member of your family. Doing so amounts to Medicare fraud.


When you find yourself being investigated for the crime of upcoding, it means you have exaggerated the treatment you offer a patient. In some cases, it could be that you billed a patient for a more expensive service than what you delivered. For example, billing for an hour’s consultation while the session only lasted ten minutes is punishable by law.

Medicare Fraud

Hiring a Medicare Fraud Lawyer Can Help

All Medicare fraud cases are complex, and trying to figure them out on your own will leave you in a quagmire of information. All this can be overwhelming and can take much of your time. In such a case, why not hire a professional who has experience in Medicare fraud cases?

An experienced attorney will come to your defense toward obtaining a successful defense. Lawyers know the legal statutes, prosecutorial strategies, the court system, and legal processes. They also have legal resources you might not be able to access without their help. With their knowledge and expertise, they will help you form a favorable settlement agreement for a favorable court verdict.

At Meltzer & Bell, P.A, we can help you reach favorable terms for your Medicare fraud case. We strive to protect you and your interests at every step of the way during the court proceedings. We believe that you deserve the best representation for your case. Contact our team of experts today and let us walk this journey with you to the best of our ability.

    Leave a Reply

    Your email address will not be published. Required fields are marked *