Under ORC 2913.40, MEDICAID FRAUD occurs when a Medicaid provider knowingly makes or causes to be made a false or misleading statement or representation for use in obtaining reimbursement from the medical assistance program. This would include but is not limited to, billing for services not provided, charging Medicaid more than the reasonable value of the services, providing services that were medically unnecessary, etc.
Medicaid providers include doctors, dentists, hospitals, nursing homes, pharmacies, clinics, counselors, personal care/homemaker chore companies, and any other individual or company that is paid by the Medicaid program. If a provider intentionally misrepresents the services rendered, and therefore increases their reimbursement from Medicaid, Medicaid fraud has occurred.
Medicaid fraud includes:
- Billing for medical services not actually performed, known as phantom billing;
- Billing for a more expensive service than was actually rendered, known as up coding;
- Billing for several services that should be combined into one billing, known as unbundling;
- Billing twice for the same medical service;
- Dispensing generic drugs and billing for brand-name drugs;
- Giving or accepting something in return for medical services, known as a kickback;
- Bribery;
- Providing unnecessary services;
- False cost reports;
- Embezzlement of recipient funds.
Medicare Fraud Charges in New York
In New York, Medicare fraud is the receipt of Medicare reimbursement to which the individual, or the organization, is not legally entitled. There are various types of Medicare fraud, but each has the same intent: collect money from the Medicare program illegally.
Since not all Medicare fraud is detected, the total amount of funds stolen is hard to track. According to an estimate from the Office of Management and Budget, “improper payments” amounted to over $47 billion in 2010. The Congressional Budget Office guesstimates that Medicare spending totaled $528 billion the same year.
Being based on the honor system of billing, the Medicare program is ripe for fraud. The program was initially established to help honest doctors who helped the poor by providing them with medical services.
Types of Medicare Abuse
Medicare is normally defrauded in three ways:
- Phantom Billing. The provider bills Medicare for unnecessary, or never performed, procedures, as well as medical tests and medical equipment.
- Patient Billing. A patient involved in the scam provides their Medicare number in return for kickbacks. The provider bills Medicare and pays a portion to the individual providing the needed number.
- Upcoding. Inflating medical bills for using a billing code showing the patient received more expensive care and treatment than provided.
Prosecution
The Office of Inspector General for US Department of Health and Human Services is tasked with protecting the integrity of Health and Human Services programs. The investigatory office of the HHS works closely with the FBI to combat Medicare Fraud.
Defendants accused of Medicare fraud face harsh penalties as reflected in the Federal Sentencing Guidelines. The sentence depends on the amount of fraud, but convictions mean substantial prison time, fines, restitution and deportation if not an American citizen.
The Justice Department has acted to recover over $7 billion in fraudulent claims from January 2009 until June 2012. $8.9 million of that came from one hospital, Overlook Hospital, located in New Jersey. The hospital, along AHS
Hospital Corporation and Atlantic Health System, Inc., had been accused of overbilling Medicare for treating patients on an inpatient basis when those patients qualified for outpatient services.
Penalties for Medicare Abuse and Fraud
Health care providers found to have committed Medicare fraud face stiff penalties and major consequences. Typically, offenders will be mandated to repay the overpayments, and there will normally be heavy financial fines as well. Criminal prosecution by the federal government is also a probability. The usual prison term is up to five years, for each offense. Each offense is defined as each transmission of a fraudulent Medicare billing form times the number of procedures on that form. For example, a physician’s office submits a Medicare billing form for one patient who has received 5 procedures where four of those procedures result in Medicare being fraudulently billed, the person responsible is looking at 20 years in prison.
Multiply that by the number of alleged offenses by the fraudster and it is plain that significant time in prison is waiting.
Retain a Quality Medicare Fraud Defense Attorney
Any New Yorkers who have been investigated for, accused of, charged with, arrested for, or convicted of Medicare/Medicaid fraud should contact NYC-based Medicaid fraud attorneys at Law Office of Bukh Law Firm, PLLC to schedule a consultation.
Law Office of Bukh Law Firm, PLLC represents clients in matters involving Medicaid throughout New York, including allegations of:
- Coverage claims for non-existent illnesses
- Claims for coverage for staged, fraudulent auto accident injuries such as back or neck pain
- Medicare/Medicaid claims for fraudulent, falsified, or exaggerated alcohol dependency treatment
- Medicare/Medicaid claims filed under phony names
- Medicare/Medicaid coverage claims for home health care, therapy, or treatment which never occurred
Our New York Medicare/Medicaid fraud defense lawyer defends patients, doctors, medical clinics, nursing homes, assisted living facility personnel, and so-called “Medicaid mill operators” accused of filing fraudulent Medicaid or Medicare claims for non-qualifying health care services.
Even mere accusations of Medicare or Medicaid fraud can turn a medical practice upside down. Investigators will be roaming over the office, looking at files as they search for evidence. Computers may be seized, and patient records might be taken as well. Being accused of fraudulently billing the government for healthcare services, tests and equipment is one of the most serious charges a health care provider may ever face.
Bukh Law Firm have successfully defended dozens of doctors and other health care practitioners against charges of Medicare fraud.
If you are accused with such a crime, your first call must be to Bukh Law Firm. Bukh Law Firm will build a team around your defense making sure that your case has the best possible, reasonable outcome.
