Medicare billing concerns can involve mistakes, disputed medical necessity, prohibited financial relationships, or knowingly false claims. “Fraud” and “abuse” are not interchangeable labels, and a billing irregularity does not automatically prove a crime. The facts, applicable program rules, and the required mental state matter.
What conduct raises questions?
Examples include billing for a service not provided, using a code that does not describe the service, billing for a service that was not medically necessary, or paying for referrals. Some issues may lead to repayment or administrative remedies; others may trigger civil or criminal investigation. The HHS Office of Inspector General summarizes the False Claims Act, Anti-Kickback Statute, Physician Self-Referral Law, exclusion authorities, and civil monetary penalties. Each has distinct requirements and consequences.
Responding to an inquiry
Preserve claims, patient records, coding guidance, contracts, and communications under applicable privacy rules. Do not change records to make a claim appear different. Identify the precise claim periods and services at issue, and consult counsel before making an investigative statement or producing records. A facility owner or clinician should not assume that a staff member’s actions automatically establish personal criminal liability, or that delegation eliminates every responsibility.
Penalties and program exclusion depend on the law, findings, and case. The old blanket dollar and prison figures in this article do not apply to every allegation. Roy J. Kahn, P.A. handles health care fraud defense matters in Miami. No outcome is guaranteed. This is general information, not legal advice.
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