How can improper Medicare claims affect your practice?

The health care industry comes with stacks of government paperwork necessary for regulatory compliance. You can easily feel like you are drowning in forms, and rush to complete them. Unfortunately, hurrying through government forms, such as those required for Medicaid and Medicare claims, can lead to serious errors and consequences.

Common errors include: filling in the wrong procedural codes, listing the wrong medications or including equipment that was not used on a patient. Are you aware that even innocent mistakes can lead to serious Medicare and Medicaid fraud, or even criminal charges?

Improper claims

The Federal government estimates that health care providers improperly file 12.1 percent of Medicare payment claims. In response, the government created formal processes to protect their resources, and determine whether these improper claims were deliberate or accidental.

In 1863, the US government passed the first version of the Federal False Claims Act (FCA). Under the FCA, you are civilly liable if you knowingly contribute to a false claim submission. To be held liable, you must act knowingly, act in deliberate ignorance, or act in reckless disregard for the truth. However, the government does not need proof of specific intent to charge you with a FCA violation.


Medicare and Medicaid fraud comes with severe potential penalties including:

  • Fraud fines: up to three times the amount of the claim, plus up to $21,563 per claim for breaking the FCA
  • Criminal penalties: fines or jail time
  • Medicaid and Medicare penalties: freezing your Medicaid and Medicare payments, removing your ability to bill to Medicaid or Medicare
  • Professional penalties: you may lose your state license, cash flow or your entire business

Suspicion of a problem

Even if you are only suspicious of Medicare and Medicaid fraud within your office, it is best to contact an attorney. An attorney can investigate your business for deliberate or accidental fraud. They can help you pre-emptively disclose problems to the Federal Government. It is better to raise your concerns before the government raises an alarm on your practice. Burying problems lead to worse legal repercussions than addressing them head on.

Penalties may start from the time of investigation, so it is important to immediately speak with an attorney. An attorney can help you work with the Medicare Fraud Control Unit, protect your practice and fight against criminal charges.

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