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Medicare / Medicaid Fraud
Millions of Americans rely on Medicaid and Medicare for health coverage. The sheer size and scope of these programs means that they are heavily regulated, but also that the federal government is always looking for instances of supposed fraud.
Because of this intense scrutiny, both patients and medical professionals can find themselves facing allegations of wrongdoing—even when they are guilty of nothing more than innocent mistakes or honest oversights. Documentation is enormously critical in these cases, and just as patients should maintain documents they receive from their physicians, health care providers also need to ensure all coding and billing is as accurate as possible.
Allegations of fraud relating to Medicare or Medicaid typically involve one of five federal statutes. Depending on the specific offense, an alleged offender may incur civil and/or criminal penalties.
Dallas Medicare Fraud Lawyer
Are you being investigated for or have you been charged with Medicaid or Medicare fraud? You can give yourself the best chance of achieving the most favorable outcome to your case by having experienced legal representation.
The Fort Worth Medicaid fraud attorneys at The Law Offices of Richard C. McConathy aggressively defend clients all over North Texas, including North Richland Hills, Mesquite, Carrollton, Highland Park, Mansfield, Frisco, Flower Mound, Richardson, McKinney, and many other surrounding communities. Call (972) 233-5700 right now to schedule a free, confidential consultation that will allow our firm to provide an honest and thorough evaluation of your case.
Texas Medicare / Medicaid Fraud Overview
- What are the possible penalties of being paid for false or fraudulent claims?
- How are kickbacks defined and handled?
- What is the Stark law?
- Can businesses be liable for working with individuals or entities excluded from these programs?
- What other violations can result in civil penalties?
The False Claims Act (FCA) allows the federal government to recoup damages from any individual (including organizations, agencies, or other entities) that receive payment from the federal government for false or fraudulent Medicare or Medicaid claims. An alleged offender can be liable under the FCA for committing or conspiring to commit any of the following acts:
- Knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval
- Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim
- Having possession, custody, or control of property or money used, or to be used, by the government and knowingly delivering, or causing to be delivered, less than all of that money or property
- Being authorized to make or deliver a document certifying receipt of property used, or to be used, by the government and, intending to defraud the Government, making or delivering the receipt without completely knowing that the information on the receipt is true
- Knowingly buying, or receiving as a pledge of an obligation or debt, public property from an officer or employee of the government, or a member of the Armed Forces, who lawfully may not sell or pledge property
- Knowingly making, using, or causing to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the government, or knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay or transmit money or property to the government
An alleged offender faces possible civil monetary penalties (CMPs) of $11,000 per claim filed plus up to three times the amount of damages the government sustains as well as the costs of bringing the civil action. Criminal penalties may include up to five years in prison and fines.
The Anti-Kickback Statute (AKS) prohibits knowingly and willfully soliciting or receiving any remuneration directly or indirectly, overtly or covertly, in cash or in kind, in exchange for referrals or the generation of business involving any item or service payable by Medicaid or Medicare. Violations are punishable by CMPs of up to $50,000 per violation as well as up to three times the amount of the alleged kickback, and criminal penalties may include fines of up to $25,000 per violation and up to five years in prison for each violation.
There could also be administrative sanctions that exclude the alleged offender from participating in federal health care programs. It is also important to note that under the Patient Protection and Affordable Care Act (PPACA, also referred to as the Affordable Care Act, the ACA, or "Obamacare"), AKS violations automatically constitute FCA violations as well. The Office of Inspector General (OIG) has published several safe harbor regulations for payment and business practices that are not treated as violations of the AKS, even though they potentially implicate the statute.
Commonly referred to as the Stark law, the Physician Self-Referral Law prohibits physicians from making patient referrals to entities with which the physician or an immediate family member has a financial relationship for “designated health services” that are paid by Medicare or Medicaid. Under this statute, the term designated health services includes any of the following:
- Clinical laboratory services
- Physical therapy services
- Occupational therapy services
- Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services
- Radiation therapy services and supplies
- Durable medical equipment and supplies
- Parenteral and enteral nutrients, equipment, and supplies
- Prosthetics, orthotics, and prosthetic devices and supplies
- Home health services
- Outpatient prescription drugs
- Inpatient and outpatient hospital services
- Outpatient speech-language pathology services
The Physician Self-Referral Law is a strict liability statute, which means proof of specific intent to violate the law is not required. Alleged violations may be punishable by CMPs of up to $15,000 per service, civil assessments of to three times the amount claimed, and possibly being ordered to refund full amounts for all services referred. Sanctions can also include exclusion from Medicaid or Medicare programs and violations can have FCA liability.
This statute states that the OIG will exclude individuals and entities from participation in Medicare or Medicaid programs if they have been convicted of any of the following criminal offenses:
- Medicaid or Medicare-related crimes
- Neglect or abuse of patients
- Felony offenses relating to the delivery of a health care item or service, fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct
- Felony offenses relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance
Excluded physicians cannot bill directly for treating Medicare and Medicaid patients or indirectly through an employer or a group practice. Businesses can be responsible for employing or contracting with excluded individuals or entities, and violations may result in CMPs and/or obligations to repay any amounts attributable to the services of excluded individuals or entities.
In addition to the statutes listed above, this statute authorizes the OIG to seek CMPs ranging from $10,000 to $50,000 per violation for any of the following offenses relating to improperly filed claims:
- Failing to grant timely access, upon reasonable request, to the Inspector General of the Department of Health and Human Services (HHS), for the purpose of audits, investigations, evaluations, or other statutory functions of the Inspector General of the Department of HHS
- Knowingly making or causing to be made any false statement, omission, or misrepresentation of a material fact in any application, bid, or contract to participate or enroll as a provider of services or a supplier under Medicaid or Medicare
- Knowing of an overpayment and not reporting and returning the overpayment
This statute also authorizes the OIG to seek CMPs ranging from $2,000 per individual to three times the amount of payments made to the alleged offender for payments made, directly or indirectly, to induce reduction or limitation of services.
Find a Medicaid Fraud Lawyer in Fort Worth
If you have been charged with or are under investigation for alleged fraud relating to Medicaid or Medicare, do not delay in obtaining legal counsel. The Law Offices of Richard C. McConathy fights on behalf of clients in Dallas County, Tarrant County, Collin County, and Denton County.
Our firm serves several areas in North Texas, such as Denton, Hurst-Euless-Bedford, Irving, Southlake, Grand Prairie, Lewisville, Arlington, Plano, University Park, and Allen. You can receive a free consultation when you call (972) 233-5700 today so our Dallas Medicare fraud attorneys can review your case and help you understand all of your legal options.