Common Types of Medicare Frauds

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As per the legal definition, healthcare fraud is a felony in which medical claims are dishonestly presented to profit from corrupt payments. Healthcare fraud can take numerous forms, including that done by healthcare practitioners and that committed by healthcare insurance members. One can contact a skilled attorney to report medicare fraud and proceed with the case as per the federal False Claims Act. 

Laws Against Healthcare Fraud

In the USA, healthcare fraud cases are handled by the Federal Bureau of Investigation (FBI). Federal law infractions are investigated by the US Department of Justice, while the Department of Health and Human Services Inspector General Office is in charge of administrative lawsuits. While kickbacks are subject to state and federal law enforcement investigation, false claims are covered under the federal False Claims Act. The Patient Referral Act and other state statutes, as well as federal ethics, prohibit self-referrals.

Healthcare fraud is one of the offenses most often prosecuted under the federal False Claims Act (“FCA”). The FCA has been successful in recovering billions of dollars for taxpayers from dishonest hospitals, pharmacies, physicians, and pharmaceutical corporations. The FCA’s qui tam provisions may allow people to report medicare fraud. The law offers private citizens the chance to provide the government with information in exchange for a part of any eventual settlement or judgment. 

Healthcare Fraud Types

Healthcare fraud is a crime that is sometimes committed by doctors and other healthcare professionals. Here are some types- 

Non-compliance with Medicare and Medicaid Prescription Drug Pricing Structure

If a pharmacy offers in-store discounts to consumers without Medicaid or Medicare coverage while charging the government total price for the same prescription against program guidelines, the pharmacy may be the target of a successful False Claims Act claim. According to the laws, a pharmacy must charge Medicare and Medicaid patients the drugs’ fair market value, which must be the same for all clients. 

Kickback Schemes

The healthcare sector is rife with kickbacks. In general, it is against the law for any doctor or medical facility to accept anything of value (such as cash, equity, or gifts) from some other doctor, medical provider, pharmaceutical company, medical device manufacturer, or anyone else to refer patients at a specific rate, reach a certain quota, prescribe a specific drug, utilize a specific medical device, or make any other decision that could be tainted by the offering rather than being based on expertise and the law. 

Services That Are Not Medically Necessary

Only medically essential procedures or expenses are eligible for Medicaid and Medicare coverage. If the doctor is referring patients to tests, procedures, imaging, or any other medical activity that appears to be medically unnecessary or irrelevant to the treatment, the referral may be medically unnecessary and in contravention of federal healthcare standards.

Letting Examinations/treatments be Performed by Employees and Nurses

Doctors can only carry out some procedures according to Medicare and Medicaid billing regulations. Yet, a new practice is letting nurses or office staff take care of standard outpatient procedures while paying the government for the expense of the doctor’s time spent doing the service. This could put the patient in danger if a staff person performing a complicated medical treatment is unskilled or undertrained, in addition to being illegal and misleading claims. 

Conclusion

The attorneys have experience with a variety of healthcare fraud cases, and one can get in touch with them if patients notice any dubious billing practices and report medicare fraud. The professionals will take their duty seriously to safeguard any reporting of confirmed or suspected fraud and abuse.

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