What to expect from a Medicaid or Medicare fraud investigation

Even honest billing mistakes can lead to devastating effects for a health care provider. Take overbilling for example. Health care providers occasionally receive overpayment for Medicare or Medicaid. These issues can easily be resolved with a refund. Unfortunately, if the issue is not fixed quickly then the provider can face serious consequences.

If you do not catch and resolve billing issues then the government may subject you to a Medicaid or Medicare fraud investigation. An investigation can negatively impact your business, your license and your reputation. The government may even seek to press fraud charges. Medical professionals aware of billing errors or fraudulent activity should contact an attorney specialized in health law immediately.

What are the consequences of Medicaid/Medicare fraud investigations?

Medicaid and Medicare fraud accusations can lead to the following consequences:

  • Losing the ability to bill Medicaid or Medicare
  • Serious fines
  • Losing customers
  • Suspension or loss of a medical license
  • Criminal charges

Providers may face civil or criminal penalties due to federal laws governing Medicare fraud and abuse. These laws include:

  • Anti-Kickback Statute (Stark Law)
  • False Claims Act (FCA)
  • Social Security Act
  • Physician Self-Referral Law (Stark Law)
  • United States Criminal Code

For example, you can be fined if an investigator accuses you of knowingly submitting a claim to Medicare for a higher level of service than actually provided. The fines can be a sum up to three times the amount of damages sustained by the government, plus up to $21,563 per false claim filed. In addition to the fines, the provider may also be subjected to criminal fines or even imprisonment.

How does the investigation process work?

Medicaid and Medicare fraud investigations are triggered due to one of three ways:

  1. An employee witnesses fraud and reports it to CMS
  2. A patient notices billing issues and files a complaint
  3. An analyst notices a likely pattern of abuse

First you will receive a letter notifying you of a fraud investigation. A team will take the case on, working to uncover patterns of possible upcoding, unbundling, claims for falsified patients, illegal fee sharing, billing for services not received, double-billing or other types of fraud. Providers can face consequences whether the issues were the result of a mistake or an intentional act.

You will need to submit a number of documents ranging back months or possibly years. You and your employees will likely be interviewed by the investigator. You do not need to face these interviews alone. An attorney can manage conversations with FBI agents or the Medicare Fraud Control Unit to keep investigations from disastrous consequences.

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