As you might imagine, it’s much easier for doctors and nurses to commit Medicare fraud than patients themselves. This is because medical practices are the ones billing Medicare for their services. But occasionally, patients are accused of being complicit in Medicare fraud.
Full Answer
Can a nurse practitioner be charged with healthcare fraud?
Jan 06, 2022 · The large sums of money being scammed out of elderly people is part of the reason why Medicare Fraud Strike Force Teams across the country spend their days trying to shut down these types of dishonest healthcare professionals. In some cases, they net extremely positive results.
Who are the most common defendants in healthcare fraud cases?
Fraud & Abuse Laws. The five most important Federal fraud and abuse laws that apply to physicians are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL).
Can I be charged with healthcare fraud in Pennsylvania?
Oct 12, 2017 · In 2015, a Jacksonville fertility clinic settled Medicare fraud charges for billing by physician extenders. The government claimed that PA’s and nurse practitioners were billing “incident to” services when the clinic’s owner, Dr. Michael Fox was not in the office. In fact, prosecutors said at times, he wasn’t even in the United States.
What is the connection between kickbacks and Medicare fraud?
Jun 19, 2015 · The FBI arrested 46 doctors and nurses across the country this week in the largest Medicare fraud bust ever. In total, 243 people were arrested in 17 cities for allegedly billing Medicare for $712 ...
Why do doctors commit healthcare fraud?
Physicians may perform unnecessary procedures to increase reimbursement, compromising patient safety. When medical providers bill for services never rendered, they create a false medical history for patients that may later cause them difficulty in obtaining disability or life insurance policies.
What happens to a doctor who commits Medicare fraud?
Penalties: Penalties for physicians who violate the Stark Law may include fines, CMPs for each service, repayment of claims, and potential exclusion from participation in the Federal health care programs.
Is billing for non physician providers fraud?
CMS has very strict rules on billing by non physician practitioners. A violation of those rules can give rise to whistleblower awards under federal and state Medicare fraud laws.Oct 12, 2017
What factors might be red flags for Medicare fraud?
Some red flags to watch out for include providers that:Offer services “for free” in exchange for your Medicare card number or offer “free” consultations for Medicare patients.Pressure you into buying higher-priced services.Charge Medicare for services or equipment you have not received or aren't entitled to.More items...
What are the major types of healthcare fraud and abuse?
Some of the most common types of fraud and abuse are misrepresentation of services with incorrect Current Procedural Terminology (CPT) codes; billing for services not rendered; altering claim forms for higher payments; falsification of information in medical record documents, such as International Classification of ...Sep 16, 2009
Why is healthcare fraud and abuse a significant problem?
Fraud, waste and abuse diverts significant resources away from necessary health care services, which results in paying higher co-payments and premiums, and other costs. Fraud can also impact the quality of care you receive and even deprive you of some of your health benefits.Oct 1, 2021
What is the difference between healthcare fraud and abuse?
What is health care fraud and abuse? Fraud is an intentional deception or misrepresentation of fact that can result in unauthorized benefit or payment. Abuse means actions that are improper, inappropriate, outside acceptable standards of professional conduct or medically unnecessary.
Which is an example of provider fraud associated with the costs of health care services provided to patients?
Examples of common healthcare fraud activities include billing for no-show appointments, submitting claims for services at a higher complexity and claims reimbursement level than provided or documented, billing for services not furnished, and paying for referrals.Jul 14, 2017
What is the federal False Claims Act?
The federal False Claims Act pays whistleblower rewards to anyone having inside information about Medicare, Tricare or Medicaid fraud. Included are cases involving false or misrepresented credentials. Rewards are typically between 15% and 30% of whatever the government collects from the wrongdoers. In this case, Dana Dove ...
Who is Dana Dove?
Dana Dove was employed by UCI as a medical coder. Dove was also qualified as an auditor and compliance professional. The other whistleblower, Debbie Rathbun, was employed as UCI’s credentialing supervisor.
Is Medicare fraud a victimless crime?
Medicare fraud is never a victimless crime. Of special note in this case is UCI’s majority shareholder is BlueCross BlueShield of South Carolina. If anyone should have known better it is certainly Blue Cross. The defendants were allowed to settle without any admission of wrongdoing.
How much money did the Medicare scam cost?
On June 2016, the DOJ charged five Brooklyn residents with conducting an eight-year, $86 million Medicare scam in which kickbacks were paid to doctors and other healthcare providers in exchange for patient referrals and recommendations for unnecessary surgery. They also paid cash to impoverished Medicare beneficiaries who were willing to undergo non-essential medical procedures, as a way of billing the government for more business. All told, it is alleged that the group was able to funnel $36 million into their possession through private shell companies.
How many people were charged with fraud in 2016?
A recent June 2016 sweep by the Department of Justice (DOJ) charged 301 people for over $900 million worth of fraudulent claims, which included instances of embezzlement, falsifying patient records, and widespread violations of the Anti-Kickback Statute.
What are some examples of W-2?
Some of the more common examples include, but are not exclusive to: 1 Material Gifts: e.g. golf clubs, gold pens, etc. 2 Live Event Tickets: e.g. sporting events, shows, etc. 3 Lucrative Speaking Engagements: Paid with exorbitant fees or used as justification for luxury holidays or vacations 4 Unauthorized Commissions Structure: Only employees with a W-2 status are eligible for commission-based payments when dealing with Medicare/Medicaid/Tricare. Contractors with a 1099 status are not permitted 5 Free Labor: Technicians, nurses, and the like who can work for free in their hospital or clinics 6 Free Billing: Billing services or consulting advice 7 Hirings: Medical companies cannot use someone inside a referral source, or otherwise#N#aiding career prospects. People with “bona fide” credentials are still eligible, however 8 Space Rental: Illegal when the price is not within fair market value 9 Paid Preceptorships: Physicians may get paid to work as preceptors in nursing or medical schools 10 Phony Research Grants: Thousands of dollars can be spent to fund fake research projects which are then granted to conniving doctors
Why are kickbacks important?
Kickbacks encourage an inherent negligence that places the health and welfare of patients at risk. Medicare and Medicaid recipients have proven to be particularly vulnerable to these schemes. Because of their precarious clinical conditions, nursing home and hospice residents are less likely to receive scrutiny after they pass away.
What is anti kickback?
Giving anything of value to healthcare providers in exchange for patient or treatment referrals paid for by Federally-funded programs constitutes a violation of the “Anti-Kickback Statute.”. Any willful infringement of this law is punishable by fine, imprisonment or loss of business from government programs such as Medicare, Medicaid and Tricare.
Who is the medical director of Home Care Hospice?
On June 2013, Dr. Eugene Goldman, Medical Director of Home Care Hospice Inc, was found guilty of four counts of violating the Anti-Kickback Statute. From 2003 to 2008, Goldman received $263,000 in funds from the hospice which noted as his salary but were, instead, kickbacks for illegal referrals. The doctor was eventually sentenced to 51 months in prison and fined $309,000.
What is a kickback in healthcare?
At the behest of a compromised healthcare provider, patients have been sent to subpar medical facilities, given excessive or incorrect medication, or subjected to unnecessary treatments and surgeries. Kickbacks encourage an inherent negligence that places the health and welfare of patients at risk. Medicare and Medicaid recipients have proven ...
What is the False Claims Act?
That law allows healthcare professionals with inside knowledge about Medicare or Medicaid fraud to file a lawsuit against the wrongdoer.
What is the Duke University lawsuit?
In 2014, Duke University settled a False Claims Act lawsuit alleging that the hospital was billing the government for services provided by physician assistants (PA’s) during coronary artery bypass surgeries when the PA’s were acting as surgical assistants which was not allowed under government regulations. The hospital system was also charged with increasing billing by unbundling claims when the unbundling was not appropriate. The allegations all dealt with specifically cardiac and anesthesia services.
Can a nurse practitioner bill for surgery?
Obviously, they must also comply with state licensing requirements. If the practitioner truly helps the doctor with performing the actual surgery, he or she can bill as an assistant at surgery and receive 85% of the physician rate.
Do you have to be present in the house for incident to billing?
Unless the patient resides in an area designated by the government as underserved, the doctor must be present in the house in order for “incident to” billing rules to apply.
Does Medicare pay for incident to services?
Medicare pays for services rendered by a physician’s employees only certain criteria are met. These are called “ incident to” services. According to CMS, “To qualify as ‘incident to,’ services must be part of [the] patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.” The physician need not be physically present in the patient’s treatment room while these services are provided, but he or she must provide direct supervision and must be present in the office suite to render assistance, if necessary.
What happens if you have evidence of shady payments for medical referrals or prescriptions?
If you have evidence of shady payments for medical referrals or prescriptions — including payments in kind, like lavish travel funded by a drug company — or if you know of doctors who refer patients to their own businesses, or businesses owned by family members, you may be able to help the government in its fight against illegal kickbacks and Medicare fraud.
What is the Stark Law?
The term “Stark Law” refers to a series of related measures that forbid doctors and their family members from referring federally insured patients to use businesses in which the physician has a financial interest, either via ownership or any form of compensation.
Why is the quid pro quo important?
The quid pro quo is clear, if sometimes unspoken. To ensure that decisions are made in the best interest of patients — and because U.S. taxpayers can get stuck with higher bills via programs such as Medicare — medical kickbacks have been targeted by the federal government.
Is it a crime to pay a kickback?
The Anti-Kickback Statute makes it a crime to pay, offer, or solicit any remuneration to induce or reward any person for referring, recommending, or arranging for the purchase of any item for which payment may be made under a federally-funded healthcare program.
Is Medicare fraud a kickback?
The connection between kickbacks and Medicare fraud is clear. Indeed, illegal kickbacks are treated as automatic violations of the False Claims Act, the main statute that protects U.S. taxpayers from healthcare fraud, when they involve services paid by the federal government. Do you know what counts as a kickback, and how to recognize examples? Here's a short primer on the law of kickbacks and Medicare fraud.
Proving that a Doctor Committed Healthcare Fraud
To prove that a doctor committed healthcare fraud, a prosecutor must prove the following elements beyond a reasonable doubt—or beyond a doubt based upon ordinary reason and common sense:
Possible Penalties upon Conviction
Crimes involving healthcare fraud are serious and can result in severe criminal penalties, depending upon the amount of the claim involved. Such penalties can include the payment of large fines, the payment of restitution to the victims, and jail time.
Contact a Philadelphia, Pennsylvania, Healthcare Fraud Defense Attorney Today to Discuss Your Case
If you are a physician and have been charged with healthcare fraud, attorney Brain J. Zeiger can discuss the facts of your case, work to formulate potential legal defenses to your charge, and represent you in court if necessary.