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Can I Be Criminally Charged if My Employer Commits Medicare Fraud

September 19, 2023

Individuals can indeed face criminal consequences if their employer commits Medicare fraud, depending on their level of involvement, knowledge of the fraudulent activities and extent the individual falsely certified information to Medicare and profited from the scheme. Medicare fraud involves intentionally submitting false information or claims to the Medicare program in order to obtain unauthorized payments or benefits. If you are aware of your employer’s fraudulent activities and actively participate in them, you could be held both criminally and civilly liable for your role in the fraud.  If you’re aware of Medicare fraud at your company you should speak with an attorney about your options, before someone from the government speaks with you as you may run out of options, be viewed as a target of the investigation and spend money on defense attorneys, instead of potentially reporting the fraud through the False Claims Act and making yourself eligible for a whistleblower award. 

Please note that this should not be considered legal advice and nothing herein can be relied on. If you’re aware of Medicare fraud you should try to have a free, confidential consultation with one of the best whistleblower law firms who focuses on False Claims Act litigation if you’re thinking about blowing the whistle. Here are a few things to consider regarding your potential exposure:

Active Participation in Medicare Fraud

Active participation in Medicare fraud involves directly engaging in fraudulent activities with the intention of deceiving the Medicare program for financial gain. Here are some examples of what active participation might entail:

False Claims Submission: A medical billing clerk knowingly submits claims for medical services that were never provided to patients. They manipulate patient records to make it appear as though the services were rendered.

Altering Medical Records: A physician alters patient medical records to exaggerate the severity of a patient’s condition, resulting in higher reimbursement rates from Medicare for services that were not necessary.

Upcoding in healthcare: A healthcare provider deliberately assigns incorrect billing codes to medical procedures to bill Medicare at a higher rate than the services actually provided. An example of upcoding in healthcare could be when a simple medical procedure might be coded as a more complex one to increase reimbursement.

Kickbacks in healthcare: A medical equipment supplier offers financial incentives to healthcare providers in exchange for referring patients to use their products. Kickbacks in healthcare compromises the integrity of the treatment decisions and violates anti-kickback laws.

If you engage in these activities knowingly and with the intent to defraud Medicare, you could be charged with various offenses, including healthcare fraud and conspiracy.  The only following orders of defense will be looked at in terms of the extent of your role in the scheme. Were you the one signing off on compliance?  Did you directly profit from the scheme?  Or did you have to participate in the fraud to keep your job and you didn’t receive any additional streams of compensation? These are the things that you should consider and a Medicare fraud lawyer will help you evaluate.   

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Knowledge of Medicare Fraud

Having knowledge of Medicare fraud within your workplace and not taking any action to address it or report it can also have legal consequences if you are in a position of trust and/or compliance. Examples of this scenario include:

Medical Office Manager: A medical office manager becomes aware that a colleague is submitting false claims for unnecessary medical procedures but chooses not to report it to superiors or authorities.

Billing Specialist: A billing specialist suspects that the medical practice they work for is intentionally submitting inflated bills to Medicare but does not raise any concerns or report the suspicion to relevant authorities.

In these cases, your complicity could be based on your awareness of the fraud and your decision not to act on that information, potentially leading to charges related to aiding and abetting or failing to report criminal activities.

Unawareness and No Involvement

If you genuinely have no knowledge of your employer’s fraudulent activities and are not involved in any way, you are unlikely to face legal charges. However, if you become aware of the fraud and fail to report it, you could still encounter ethical dilemmas. For example:

Clinic Nurse: A nurse working at a clinic has no knowledge that the clinic’s management is involved in fraudulent billing practices. When the fraud is eventually exposed, the nurse’s lack of awareness may protect him or her from legal implications.

Receptionist: A receptionist at a medical facility is not involved in billing or financial matters and has no knowledge of any fraudulent activities happening within the organization. It would be hard to argue culpability. 

In these cases, as long as you remain uninvolved and unaware of the fraudulent activities, you generally would not face legal repercussions. However, if you’re deliberately being dense and there’s strong indicators that cross your radar about the fraud that you choose to ignore, there may be some exposure.

It’s important to note that legal actions in cases of Medicare fraud can vary depending on the jurisdiction, the extent of the fraud, and the roles of the individuals involved. If you suspect or become aware of Medicare fraud within your workplace, it is advisable to speak to a Medicare fraud whistleblower law firm who may encourage you to take the following steps:

Document: Keep records of any evidence you come across that indicates fraudulent activities. This can include emails, documents, invoices, or any other relevant information.  Only keep records of items that you lawfully have access to. 

Report: Prepare the information to make a report.  Your Medicare fraud law firm can give you advice about who and how to report. Oftentimes reporting internally will lead to termination.  

Distance Yourself: If you discover that your employer is involved in fraudulent activities, it’s wise to distance yourself from those activities. Taking proactive steps to disassociate yourself from fraud can help protect your reputation and legal standing.

Seek Legal AdviceSpeak to a Whistleblower Law Firm

Speak with a False Claims Act law firm if you’re aware of Medicare fraud.  If you are the primary actor who has economically benefited from it, you may need to consult with a defense attorney since other people may be blowing the whistle against you or you may be found out.