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What Is Medicaid Fraud?

In the US, over 75 million people participate in the Medicaid program. Given the size of the program, it isn’t surprising that Medicaid fraud is common. That doesn’t mean, however, that authorities overlook instances of fraud within the program. On the contrary, it is aggressively investigated and prosecuted by state and federal officials.

If you have been accused of this crime, contact Medicaid fraud attorney Michael J. Wynne immediately to ensure that you have someone on your side who has the experience and tenacity necessary to defend you against those accusations.

Medicaid Basics

Medicaid is a health care program primarily funded by the federal government; however, it’s administered by the individual states. An allegation of Medicaid fraud may be investigated and prosecuted by the state and/or federal government.

What Is Medicaid Fraud?

In broad terms, Medicaid fraud involves the payment of benefits or funds from Medicaid when the funds were not properly owed or the recipient was not entitled to the benefits. It can be a civil violation or a criminal offense. Some common examples of scenarios that constitute fraud on the part of a provider include:

  • Billing for services or equipment that are unnecessary
  • Billing for services or equipment that were never provided
  • Upcoding (billing at a higher level than the services justified)
  • Unbundling (using multiple billing codes when one code would suffice)
  • Card sharing (knowingly treating someone who is using someone else’s Medicaid card)
  • Kickbacks (paying or accepting money for patient referrals)

Examples of conduct that amounts to fraud on the part of a Medicaid recipient include:

  • Card sharing (letting someone else use your card)
  • Collusion (helping a doctor file false claims by getting tests or procedures you don’t need)
  • Kickbacks (accepting money or drugs from a doctor for referring patients)
  • Application fraud (providing false information to be eligible for benefits)
  • Multiple state participation (applying for and using benefits in more than one state)

Medicaid Fraud Laws and Enforcement

At the federal level, there are three statutes that can govern conduct relating to Medicaid fraud, the False Claims Act, the Anti-Kickback Statute and Stark Law. The most frequently used statute is the False Claims Act, which makes it a federal offense to submit any “false or fraudulent” claim to the government.

The False Claims Act provides for both civil and criminal penalties for a violation of the Act. Civil penalties include fines, recoupment of overbilled amounts and exclusion from Medicaid and other government health care benefit programs. Along with recoupment and exclusion, criminal penalties for violating the False Claims Act include up to a $250,000 fine and/or up to five years in prison.

The state of Texas also has a similar statute, known as the Medicaid Fraud Prevention Act, that governs fraud at the state level. Texas law also provides for both civil and criminal penalties if convicted. Along with stiff fines, you face up to five years in prison following a conviction.

Contact Medicaid Fraud Attorney Michael J. Wynne Today

While there are undoubtedly individuals who intentionally set out to defraud the program, accidental Medicaid fraud occurs frequently as well. The complexity of the system itself can easily lead providers or participants to make honest mistakes that lead to accusations of fraud.

If you find yourself accused, you need Medicaid fraud attorney Michael J. Wynne on your side to ensure that your voice is heard throughout the ensuing judicial process. Contact him immediately by calling 713-942-2255 to schedule a consultation.

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