What is Medicare & Medicaid Fraud?
The Federal statute which criminalizes Medicare and Medicaid fraud is located at Title 18 United States Code Annotated Section 1347. The law states:
18 U.S. Code § 1347 – Health care fraud
(a)Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice—
(1)to defraud any health care benefit program; or
(2)to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.
(b)With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.
The types of Frauds typically committed in violation of this law are:
- Frauds charging for services or medical products never provided. A medical provider or medical product supplier may submit bills to the government for services never provided either for real patients or fictitious patients.
- Frauds over charging for services or medical products provided to patients. This is called up-coding. A doctor enters a medical billing code to the government for reimbursement for a condition more serious and more costly than what the patient actually needed. Alleged up coding is the most likely type of activity to ensnare and innocent medical provider who simply made unintentional coding errors or who believes that a condition is better treated by the more costly procedure versus the less costly procedure that is typically recommended.
- Frauds providing unnecessary medical products or services to patients. A provider or medical product supplier might prescribe to the patient and bill to the government procedures or products and provide those procedures and products to the patient but the procedure or product was not requested by the patient or was not necessary.
The key to whether any action is a violation of this law is the requirement that the person act with the knowledge and intent to commit fraud. Simple mistakes in coding or charging for a more costly procedure when medical science justifies a more costly procedure are not crimes.