The prosecution of Medicare fraud is a high priority for federal prosecutors across the country. The estimated loss of federal funds to Medicare fraud is $60 billion annually. Â
Under federal statute 18 U.S.C. § 1347, Medicare fraud occurs when an individual knowingly and willfully executes, or attempts to execute a scheme or artifice, that defrauds any healthcare benefit program by use of false pretenses, representations, or promises, committing a federal offense. The prosecution must establish the defendant’s intent to defraud to secure a conviction under this statute.Â
At Stechschulte Nell, Attorneys at Law, our years of experience and comprehensive understanding of federal law and procedure have allowed us to achieve an impressive record of success defending healthcare providers and others accused of Medicare fraud and related offenses. The unlimited resources available to the government in prosecuting Medicare fraud defendants make it essential to have experienced federal defense counsel by your side. If you are facing Medicare fraud charges in Florida, contact our office today. Â
 Â
Types of Medicare FraudÂ
Medicare fraud encompasses various illegal activities aimed at unlawfully obtaining funds from healthcare benefit programs. The most common forms include:Â
- Upcoding: Using billing codes corresponding to more expensive services than those performed.Â
- Unbundling: Billing each stage of a procedure separately instead of using a single comprehensive code to increase reimbursement.Â
- Kickbacks: Receiving or offering payment to induce referrals for services or products covered by Medicare.Â
- Patient Fraud: Patients providing false information to receive services or benefits they are not entitled to.Â
- False Cost Reports: Submitting fraudulent cost reports to receive higher reimbursements. Â
- Billing for Services Never Rendered: Submitting claims for medical services, treatments, or supplies that were never provided to patients.Â
Penalties for Medicare FraudÂ
Medicare fraud is severely penalized under federal law. The penalties vary depending on the specific conduct involved in each case and the amount of loss caused to the Medicare program. Penalties include:Â
- Imprisonment: Convicted offenders face up to 10 years in prison, per count. If the fraud involves serious bodily injury to a patient, the sentence can increase to 20 years. In cases involving a patient’s death, the penalty can be life imprisonment.Â
- Fines: Those convicted of Medicare fraud face significant fines of up to $250,000 for individuals and $500,000 for organizations.Â
- Restitution: Courts often order restitution, requiring the offender to repay the full amount of the fraudulent amounts to the Medicare program. Â
- Exclusion from Federal Programs: Convicted individuals or entities are typically excluded from participating in Medicare, Medicaid, and other federally funded health programs.Â
Other Federal Statutes Related to Medicare FraudÂ
Other federal statutes cover various aspects of healthcare fraud that closely track the Medicare fraud statute:Â
18 U.S.C. § 287 – False Claims Act: This statute prohibits submitting false claims for payment to the federal government, including healthcare programs. Penalties include fines of $13,946 to a maximum of $27,894 for each false claim.Â
42 U.S.C. § 1320a-7b – Anti-Kickback Statute: Prohibits the exchange of remuneration to induce referrals for services covered by federally funded programs. Violations can lead to fines, imprisonment, and exclusion from federal healthcare programs. Penalties include up to 10 years in federal prison and up to $100,000 per count.Â
18 U.S.C. § 1033 – Insurance Fraud: This statute criminalizes fraud related to the insurance business, including making false statements or reports. The penalty is up to 10 years in prison per count and up to 15 years in some circumstances.Â
The Office of the Inspector General (OIG) also has the authority to disqualify providers who violate the Anti-Kickback Statute from participating in federally funded programs such as Medicare, Medicaid, and VA healthcare services. Furthermore, the Civil Monetary Penalties Law allows the OIG to impose civil penalties for violations of the Anti-Kickback Statute, among other provisions.Â
Defense Strategies Against Medicare Fraud ChargesÂ
Defending against Medicare fraud charges requires a thorough understanding of the law and the ability to closely scrutinize the evidence presented by the prosecution. The best defense strategy for each case depends on the unique facts and circumstances involved, but may include one or more of these:Â
- Lack of Intent: Challenging the prosecution’s ability to prove the defendant’s intent to defraud is often the single most powerful defense. Since intent is the primary element of Medicare fraud, demonstrating the absence of intent is often an effective defense. This can involve showing that the accused person or organization made an honest mistake or misunderstood billing procedures.Â
- Insufficient Evidence: Challenging the sufficiency and credibility of the evidence is a standard defense in every case because success in that effort can lead to a dismissal or reduction of charges. This involves examining every single aspect of the prosecution’s evidence and identifying weaknesses or inconsistencies that raise doubt in the mind of the jury.Â
- Compliance Programs: Demonstrating that the accused had robust compliance programs in place to prevent fraud can counteract the prosecution’s claim of intent. This shows that any alleged fraud was contrary to the organization’s policies and efforts.Â
- Duress or Coercion: If the accused was forced to participate in fraudulent activities under threat or coercion, this can also serve as a defense. This is a very fact-dependent defense strategy but is extremely effective when supported by surrounding facts.Â
Role of Experienced Legal RepresentationÂ
Florida’s Stechschulte Nell, Attorneys at Law, brings extensive experience and a proven track record in defending clients against federal fraud charges. Our federal court experience is frequently instrumental in defeating federal prosecutions of clients, especially in complex and technical cases.Â
Medicare fraud is a complex and serious crime with severe penalties. Understanding the common forms of fraud, the penalties involved, and the related federal statutes is essential for anyone involved in the healthcare sector. Â
Having the knowledgeable legal defense team at Stechschulte Nell, Attorneys at Law, on your side can make a significant difference to the outcome of a case. The firm’s experience and dedication to clients and their families ensure every defendant a thorough and tailored strategic defense focused on achieving the best possible result.Â
Contact us today for a comprehensive case review at 813-280-1244. Â