If you are a physician who accepts Medicare patients, there are various standards you need to follow. Medicare fraud and abuse is common, and there are steep penalties if you face conviction.
There are differences between fraud and abuse, but both are serious offenses. It is important to understand some of the activities that constitute them so you do not get in trouble.
Fraud vs abuse
The Centers for Medicare and Medicaid Services explains the difference between fraud and abuse. Fraud is when a doctor knowingly does something illegal, such as billing for services not provided or paying for referrals. Abuse refers to an action that unintentionally results in unnecessary costs to Medicare. Bending the rules runs more along the lines of abuse, while intentionally deceiving Medicare results in fraud.
Laws regarding fraud and abuse
The U.S. Department of Health and Human Services, Office of Inspector General discusses some of the fraud and abuse laws. The False Claims Act states that you cannot submit claims that are false. This can be deliberate or with no specific intent to act fraudulently.
The anti-kickback statute refers to paying, or accepting money, for referrals. This also refers to waiving copays to attract patients. You are able to waive a copay every once in a while if you determine the patient cannot pay it, but if it occurs routinely, you could face trouble.
The physician self-referral law prohibits physicians from referring patients to a diagnostic center or lab to which the physician or family member has financial ties.
Penalties for committing Medicare fraud
There is a variety of penalties someone may face if convicted of fraud. One is that the physician will no longer be able to participate in Medicare and other Federal health care programs. There are also financial penalties, and they vary depending on different factors. Monetary penalties can range from $10,000 to $50,000 per violation. There may also be fines that can be hundreds of thousands of dollars. Prison time is also a possibility.