Common Types of Medicaid Fraud

As one of Tampa and Hillsborough County’s most respected criminal defense firms, Stechschulte Nell has extensive experience representing clients accused of a wide range of criminal offenses. Among the most diverse group of clients are those charged with one or another form of Medicaid fraud.

Medicaid fraud is a serious crime that requires immediate attention by an experienced Medicaid fraud defense lawyer. Stechschulte Nell Attorneys at Law have years of litigation experience and know every facet of the prosecution’s strategies and how to counter them with sound, effective defense practices.

What Is Medicaid Fraud?

Medicaid fraud occurs when a person uses false information with the intention of getting Medicaid to pay for medical care or other healthcare-related services. Medicaid is a federally funded but state-administered program to pay for the cost of medical care for low-income, elderly, and disabled people.

Both state and federal laws prohibit fraud and Medicaid fraud can be prosecuted in either the federal courts or in our Florida courts, depending on the nature of the fraud and the role of the person committing the fraud, a Medicaid service provider, a Medicaid recipient, or a third-party beneficiary of a Medicaid fraud.

Read More> Healthcare Fraud: Protecting Your License and Reputation

Types of Medicaid Fraud Crimes

Medicaid fraud can be committed by medical providers or by those receiving the medical services being paid for by Medicaid. Additionally, the third group of people who can commit are those who are not eligible Medicaid beneficiaries but obtain Medicaid-paid services. Here are the most common ways these frauds are carried out.

Providers (Doctors, Therapists, Pharmacists, etc.):

Overbilling— Medicaid pays healthcare providers for the services they perform for eligible Medicaid recipients. But only the doctor and the patient know what services were actually performed. In many cases, the fraud involves doctors or their medical clinic business billing for more services than were every provided.

Each service a Medicaid provider performs has a corresponding code number. If a patient receives three coded medical services, a doctor may defraud Medicaid by knowingly billing for five or six coded procedures.

Phantom Office Visits — Still more fraudulent is the practice of billing Medicaid for services to a patient who never visited the doctor on the day services were billed. This is possible because medical offices collect all the necessary information required from billing for each client. Who would know if the patient actually came in for an office visit that day?

Unnecessary Tests & Procedures — One form of Medicaid fraud the U.S. Justice Department has been especially active in prosecuting is doctors ordering expensive tests or diagnostic procedures that are not medically necessary. For example, some cardiologists are in federal prison because they performed catheterization or other intrusive procedures on patients whose other tests indicated they were not appropriate for the procedure.

Unbundling or Up-coding — Medicaid has assigned codes to every covered service and product a doctor or other service provider could provide. Sometimes one code covers several related services because they so commonly go together. These “bundled” codes are paid at a lower rate than if each service were coded separately. Some doctors do the bundled services but then unbundle them for separate billing to get higher Medicaid reimbursement. Up-coding is when a simple, less expensive service is performed but the doctor bills Medicaid for a similar but more complex, more expensive version of the service.

Knowingly Conspiring to Cooperate with a Beneficiary’s Medicaid Fraud — When doctors know a Medicaid fraud is being committed by a Medicaid patient, the doctor is guilty as well.

Fraud by a Medicaid Beneficiary

Medicaid benefit recipients who defraud Medicaid commonly use several of the following tactics.

Sharing Medicaid Cards — When an eligible Medicaid beneficiary shares their Medicaid identification card with someone who is not insured so they too can get medical services paid for by Medicaid, the scheme is Medicaid fraud. This fraud creates two chargeable crimes against each participant, Medicaid fraud, and conspiracy to commit Medicaid fraud. Any agreement to commit a crime once acted upon constitutes a separate crime.

Group Collusion Fraud — A common Medicaid fraud conducted by an organized group involves many people arranging with at least one Medicaid provider to repeatedly permit the doctor to submit fraudulent bills to Medicaid for services they never received in return for a cut of the Medicaid reimbursement payments.

Eligibility Fraud — Qualifying for Medicaid coverage requires an applicant to submit detailed information about the person’s identity, their disability, their housing and living circumstances, their income and financial resources, and other facts. Knowingly providing false information in connection with a Medicaid eligibility application is another common way Medicaid fraud occurs in Florida.

Learn More> Anti-Kickback Statutes for Florida Healthcare Providers

Charged with Medicaid Fraud? Call Stechschulte Nell Law

If you are facing Medicaid fraud charges in either federal court or in Florida state courts, you need to be represented by criminal defense attorneys who know Medicaid fraud law and who know how to prevent federal or state prosecutors from overstepping their legal limits. Attorneys Ben Stechschulte and Amy Nell are one of Tampa and Hillsborough County’s best, most experienced criminal defense teams.

Your life and your family’s future depend on the quality of your criminal defense lawyer’s skill in analyzing the facts of your case, knowing the applicable law, preparing the most appropriate defense motions, and assessing the relative strengths and weaknesses of the government’s evidence.

Trust only the most knowledgeable defense attorneys in Tampa Bay. Call Stechschulte Nell Law for a case review today; 813-280-1244.

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