Medicare fraud generally involves knowingly deceptive conduct to obtain payment or benefits from the program. Allegations may concern billing for services not provided, false documentation, misuse of a beneficiary’s information, or improper payments for referrals. A coding mistake or disputed claim does not by itself establish every element of fraud.
Rules for providers
The HHS Office of Inspector General explains the distinct False Claims Act, Anti-Kickback Statute, Physician Self-Referral Law, exclusion, and civil monetary penalty rules. These are not a single offense with a fixed fine. Liability and potential remedies depend on the conduct, statute, current penalty schedule, and evidence. A referral within a practice is not automatically unlawful; financial relationships and exceptions require careful analysis.
Protecting a Medicare number
Beneficiaries can review claims and Medicare Summary Notices for services or equipment they did not receive. Medicare.gov advises protecting the Medicare number and reporting suspicious claims. Do not assume a free screening or legitimate medical service is fraudulent solely because it is free; verify the provider and offer.
If investigated
Providers and staff should preserve claims, medical records, contracts, and communications in compliance with privacy duties. Do not change records or discuss a shared account of events with witnesses. Counsel can examine the relevant billing period, coding, medical necessity, and any claimed knowledge or intent. Roy J. Kahn, P.A. handles health care fraud defense matters in Miami. No result is guaranteed. This article provides general information, not legal advice.
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