A Complete Guide to Understanding Medicare Fraud: From The Whistleblower Attorneys at Brown, LLC - Brown, LLC

A Complete Guide to Understanding Medicare Fraud: From The Whistleblower Attorneys at Brown, LLC

April 6, 2023

Healthcare continues to soar as people age, as does the potential to commit Medicare fraud, as the need for elderly services skyrockets. Healthcare fraud is a serious felony perpetrated when a healthcare practitioner makes fraudulent statements or representations to obtain payment from a government healthcare or insurance program or even a private insurance program. Medicare fraud,  Medicaid Fraud and Tricare Fraud, in particular, are a major source of concern for both the government and consumers and oftentimes rampant with fraud. When federal payers are in play then the wrongdoing can be addressed through the False Claims Act, which incentivizes whistleblowers to step forward for a portion of the recovery as a whistleblower reward.  If it’s not a federal payor then there are other statutes that individuals can be prosecuted under, but unless it implicates California or Illinois, there are no whistleblower statutes to invoke.  


What is Healthcare Fraud?

Any intentional deception or misrepresentation that results in the underserved or inflated payment of a healthcare benefit or service is considered healthcare fraud. Healthcare providers, patients, and others engaged in the healthcare industry can participate in the fraud and will have varying degrees of criminal and civil liability if engaging in the scheme. Billing for services that were never provided, billing for services at a higher rate than what was actually provided, and providing unnecessary medical services are some common types of healthcare fraud.

What Are Examples of Medicare Fraud?

Medicare fraud can take many forms, with the one staple being the billing of the government payer programs, the largest being Medicare, then Medicaid.   Some common examples of Medicare Fraud include:

  • Billing for services not rendered: Billing the government for procedures, services, or supplies that were never delivered is a widespread type of Medicare and Medicaid fraud.  This type of fraud, also known as “phantom billing,” includes charging for services such as blood tests when no samples were taken, x-rays when none were taken, dental fillings when none were completed, or home health care hours when none were actually rendered.
  • Upcoding: When a healthcare provider bills for a higher level of service than was actually provided, this is known as upcoding. For instance, billing for a more complex medical procedure than what was actually performed.
  • Double billing: When a healthcare provider bills and collects from both Medicare and a private insurance company for the same service, this is known as double billing. Double billing can also refer to when a provider bills for the same service more than once or spreads out the billing over multiple days when in fact it should have all been billed for services provided on the one occasion.
  • Kickbacks: When a healthcare provider receives payment for referring patients to other healthcare providers or suppliers, this is referred to as a kickback. Some of the largest civil settlements under the False Claims Act have been the result of pharmaceutical kickbacks.  
  • Unnecessary medical services: In order to receive Medicare payment, providers may perform unnecessary medical services or tests.

What is the Requirement for a Medicare Fraud Conviction?

Medicare fraud is the intentional submission of false or misleading information to Medicare for payment of services that were never rendered or were not medically necessary. A person may be charged with a crime if there is enough proof of their intention to commit fraud or another crime and convicted if there is proof beyond a reasonable doubt. 

There are specific elements that the prosecution must prove to secure a conviction if a person is accused of Medicare fraud. These include demonstrating that the defendant acted with the specific intent to defraud Medicare, that the defendant made false statements or representations that were material and had the potential to affect Medicare’s decision to pay for the services, and that Medicare paid the defendant as a result of the false statements.

Even if the government is not able to make its proofs under the criminal standard, it can still pursue civil remedies under the False Claims Act which is a much less onerous standard.  

What Are the Possible Medicare Fraud Sanctions?

There are a range of possible sanctions for Medicare fraud, including civil and criminal penalties. The specific sanctions will depend on the nature and severity of the fraud, as well as the individual’s criminal history and other factors.

Some possible sanctions for Medicare fraud include:

  • Civil monetary penalties
  • Exclusion from federal healthcare programs
  • Imprisonment
  • Restitution
  • Asset forfeiture
  • Professional discipline

How do you report Medicare Fraud?

Reporting Medicare fraud is crucial in protecting the integrity of the program and preventing fraud in the future. If you suspect Medicare fraud, you can report it to the appropriate government agencies; however, if you want to be eligible for a whistleblower award under the False Claims Act, you must file it with the assistance of a whistleblower law firm such as Brown, LLC, who is experienced in litigating Medicare fraud cases.

How Can Criminal Charges Apply in Medicare Fraud-Related Matters?

Healthcare fraud can be prosecuted under a number of federal statutes, including:

18 U.S.C. § 1347 – Health Care Fraud: This statute prohibits knowingly and willfully executing or attempting to execute a scheme to defraud any healthcare program, or to obtain by means of false or fraudulent pretenses any money or property owned by any healthcare program.

42 U.S.C. § 1320a-7b – Criminal penalties for acts involving federal health care programs: This statute provides criminal penalties for various offenses related to federal healthcare programs, including submitting false claims, paying or receiving kickbacks, and obstructing audits or investigations.

18 U.S.C. § 286 – Conspiracy to defraud the government with respect to claims: This statute prohibits conspiring to defraud the government by obtaining payment or approval for false or fraudulent claims.

18 U.S.C. § 287 – False, fictitious or fraudulent claims: This statute prohibits submitting false, fictitious, or fraudulent claims to the government.

18 U.S.C. § 1001 – False statements: This statute prohibits making false statements to the government in any matter within its jurisdiction.

18 U.S.C. § 1341 – Mail fraud: This statute prohibits using the mail to execute a scheme to defraud, including schemes related to healthcare fraud.

18 U.S.C. § 1343 – Wire fraud: This statute prohibits using wire, radio, or television communication to execute a scheme to defraud, including schemes related to healthcare fraud.

In addition to these federal statutes, healthcare fraud can also be prosecuted under state laws. The specific statutes and penalties will vary depending on the state

How Do Brown LLC’s Medicare Fraud Whistleblower Attorneys Stand Apart?

A Medicare fraud attorney can help you file a lawsuit against the provider and help you obtain a whistleblower award as a percentage of what the government recovers or to recover any damages that you may have suffered as a result of complaining about the fraud.

The whistleblower attorneys at Brown, LLC are committed to assisting people who have inside knowledge of healthcare fraud, including Medicare fraud, and have successfully recovered millions of dollars for whistleblowers, but past results don’t guarantee future success and offer free, confidential consultations.