Medicare provides healthcare to millions of Americans and pays billions upon billions of dollars to medical providers.
As of 2023, the Centers for Medicare & Medicaid Services stated that just under 65,750,000 people were enrolled in Medicare as of the beginning of the year.
This means that providing services to Medicare patients is a financial opportunity for doctors and others to tap into this taxpayer-funded program.
Since it is a federal program, authorities do watch providers as best as they can to ensure they are using the program properly. Most doctors do in fact follow the rules.
However, some providers and support staff use improper billing and other techniques to game the Medicare system in order to boost their income.
This is not always just because of greed or a sense that one is above the rules. Often, those accused of Medicare fraud or related violations of the law are suffering under the weight of an addiction, mental health problems or other significant personal issues.
Also, it is important to remember that not every provider who makes a mistake when billing Medicare commits fraud.
Occasional mistakes or even carelessness or inefficiency are not criminal. However, they may attract the attention of authorities which may over-react to an issue that is best solved in the civil system.
As a word of caution, though, even civil penalties for alleged Medicare fraud can be harsh and can include steep fines and a ban on accepting Medicare patients.
The penalties for criminal Medicare fraud are steep
Several different federal laws prohibit behavior that authorities commonly call “Medicare fraud” and impose criminal penalties for violations.
The criminal penalties for violating these laws are steep. For example, someone convicted of filing false claims can face up to five years in federal prison per false claim as well as fines and restitution.
A false claim does not have to be made up out of whole cloth. Padded bills or billing for appointments a patient missed are both examples of false claims.
Furthermore, Medicare fraud is usually prosecuted by federal authorities in federal court. The rules and procedures, including sentencing, in federal court are different from what one might find in state court.
These circumstances can make mounting a defense to healthcare fraud charges more complicated.
A doctor or other provider in the Richmond area accused of Medicare fraud should make sure they are evaluating their legal options early in the case.