Millions of Americans rely on Medicare for their first line of insurance against medical bills. Other Americans have been accused of using Medicare payments as a source of fraudulent revenue. What, exactly, is Medicare fraud? Basically, Medicare fraud is billing Medicare for health care services and supplies that were not required to treat the patient. More specifically, Medicare fraud can involve inflated invoices for supplies or services, invoices for health care services that were unnecessary or never provided to the patient, or falsifying patient records. We’ll examine each in turn.

Billing for unnecessary services or supplies

Many medical conditions require a variety of tests to obtain a complete and reliable diagnosis. Even pregnancy, which is rarely viewed as an illness, requires a wet mount, whiff test, vaginal pH measurement and oligonucleotide probe. Many health care providers have been tempted to add one or two unnecessary tests to this list. An individual test may only cost $30, but for 200 patients, the amount of excess billing increases in a hurry. If the unnecessary test is billed at, say, $150 per exam, the amount of fraudulent revenue can increase even more rapidly.

Such billing can be fraudulent because Medicare is only authorized to pay for services and supplies that are “medically reasonable and necessary.” If a physician submits such a statement in support of an invoice, he or she has allegedly committed fraud. Billing for unnecessary medical services or supplies, or submitting invoices for an inflated charge, is one of the most common types of Medicare fraud. Any physician who is facing allegations of fraudulent billing may, if convicted, be incarcerated, subject to a significant fine and lose the right to practice medicine. The need for competent legal representation in such cases is obvious.

Billing for services or supplies that were not provided

A similar type of Medicare fraud is billing for services or supplies that were never provided to the patient. In these cases, known as “phantom billing,” the healthcare provider charges Medicare for services or supplies that were never given to the patient. Again, the provider’s statement to Medicare that the prescribed service or supplies was “medically reasonable and necessary” may be construed to be fraudulent. Conviction again carries a heavy penalty.

Falsifying patient records

A third type of common Medicare fraud is falsifying patient records. The patient’s records can be altered to support claims for unnecessary treatments or drugs, and the resulting paper trail can be used to prevent discovery of the alleged crime. Among specific violations are the addition of phantom services, overstating the charge for a particular treatment or medication, or changing the dates and times of supposed medical treatments to inflate the invoice. Health care providers are required to certify that the invoices sent to Medicare are true and accurate. The submission of a false invoice is once again a possible Medicare fraud.

Unbundling of Services

In recent years, Medicare has allowed health care providers to combine certain items of billing, called “bundling.” A common example is including the surgeon’s fee in a claim for a knee replacement. Some providers, however, “unbundle” their fee by charging Medicare twice, once in the invoice for the surgery and once in a separate invoice for their personal services. Billing Medicare in this way once again requires the health care provider to falsely swear that the invoices are true and correct.

Anyone who has been accused of making false or fraudulent statements in support of an invoice that is intended to be paid by Medicare faces potentially severe criminal penalties. The assistance of an attorney who is knowledgeable about Medicare fraud may be invaluable. An experienced Medicare fraud lawyer can evaluate the evidence, suggest possible defenses and, if appropriate, negotiate an appropriate plea agreement.

  • In the Media:
  • abc Nightline
  • the O'Reilly Factor
  • Court TV
  • abc 2020
  • CNN
  • Larry King Live
  • The Miami Herald
  • Good Morning America