Medicare and Medicaid Fraud Defense

Healthcare fraud is a type of white-collar crime that involves the filing of False healthcare claims in order to turn a profit. Fraudulent healthcare schemes come in many forms.

  • Submitting claims for services not provided
  • Billing for items and services that are not medically necessary
  • Misrepresenting dates, frequency, duration or description of services rendered
  • Falsifying claims or medical records
  • Falsifying patient eligibility
  • Misrepresentation of the individual rendering service
  • Billing for services at a higher level than provided or necessary

Enforcement Agencies: The agencies charged with enforcing healthcare laws and regulations include: the U.S. Department of Justice (DOJ), The Office of Inspector General for the U.S. Department of Health and Human Services (OIG), the Federal Bureau of Investigation (FBI), The Centers for Medicare & Medicaid Services, the United States Attorney’s Office, as well as the Medicare Fraud Strike Force a multi-agency team made up of federal, state and local investigators.

Applicable Laws: There are a number of civil and criminal healthcare fraud laws used to prosecute health care fraud.

Criminal Enforcement

Federal Anti-Kickback Statute Violations (42 U.S.C. § 1320a-7b(b)): occurs when individual providers or healthcare organizations knowingly and willfully offer, pay, solicit, or receive any remuneration, directly or indirectly, to induce or reward patient referrals for services or supplies reimbursed by a federal healthcare program.

Florida Patient Self-Referral Act of 1992 (Fla. Stat. § 456.053): Prohibits physicians from referring patients to an entity in which the physician (or an immediate family member) has a direct or indirect ownership or investment interest. As with Stark, there are some safe harbors or exceptions.

Florida Patient Brokering Act  (Fla. Stat. § 817.505): The state’s anti-kickback statute, prohibits anyone, including healthcare providers or healthcare facilities, from giving or receiving any form of remuneration in exchange for referrals, regardless of the source of payment for the service or product.

Federal Criminal False Claims Act (18 U.S.C § 2870): Whoever makes or presents to any person or officer in the civil, military, or naval service of the United States, or to any department or agency thereof, any claim upon or against the United States, or any department or agency thereof, knowing such claim to be false, fictitious, or fraudulent, shall be imprisoned for not more than five years and shall be subject to a fine in the amount provided in this title.

Federal Healthcare Fraud Statute (18 U.S.C. §1347): Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice to defraud any health care benefit program.

False Statement Relating to Healthcare Programs (18 U.S.C. § 1035): Whoever, in any matter involving a healthcare benefit program, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or device a material fact; or makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for healthcare benefits, items, or services, shall be fined under this title or imprisoned not more than five years, or both.

Civil Enforcement

The Federal Civil False Claims Act (31 U.S.C. § § 3729-3733): prohibits a person from:

  • Knowingly presenting (or causing to be presented) to the federal government a false or fraudulent claim for payment;
  • Knowingly using (or causing to be used) a false record or statement to get a claim paid by the federal government;
  • Conspiring with others to get a false or fraudulent claim paid by the federal government;
  • Knowingly using (or causing to be used) a false record or statement to conceal, avoid, or decrease an obligation to pay money or transmit property to the federal government.

Whistle Blower Provision: The False Claims Act also allows a private citizen, or whistleblower, to bring a case against someone on behalf of the government. For example, an employee or patient can file a whistleblower, or qui tam lawsuit, if they believe you have violated the law. Our firm represents both whistleblowers and those targeted by whistleblowers.

Stark Law/The Physician Self-Referral (42 U.S.C. § 1395nn): prohibits physicians from referring patients for certain designated health services paid for by Medicare to any entity in which they have a financial relationship. Unlike the Anti-Kickback Statute, it is not a criminal statute, but a civil one, and can result in severe monetary penalties. A physician’s specific intent to violate the law is not required. There are “safe harbors” or exceptions, to these relationships so it’s best to discuss with a qualified healthcare attorney.

OIG Exclusion Authority: Allows the Office of Inspector General for the U.S. Department of Health and Human Services to exclude individuals and entities from federal healthcare programs if they are convicted of  Medicare or Medicaid fraud, or any program-related offenses.

OIG Civil Monetary Penalties: The Office of Inspector General (OIG) has the authority to seek civil monetary penalties (CMPs), against an individual or entity based on a wide variety of prohibited conduct.

Healthcare laws and regulations are in a constant state of flux. It’s always best to speak with a qualified healthcare attorney to ensure that you remain in compliance with federal and state laws and regulations. Ignorance is not a defense in today’s healthcare environment. Our team of highly skilled attorneys and professionals are here to help you before you become the focus of an investigation, and will aggressively defend you should you become the target of one.

Give us a call at 305-358-4500 or email