Medicare Fraud Defense

We defend health care providers, suppliers, vendors, and other individuals facing civil and criminal Medicare fraud charges. Our team of Medicare fraud attorneys includes a former Deputy Attorney General for Idaho’s Medicaid Fraud Control Unit and Special Assistant United States Attorney who has significant experience in health care fraud. Our team also includes attorneys with master of laws degrees in health care law who are exceptionally knowledgeable in Medicare fraud laws, CMS regulations and reimbursement issues. Our licensing attorneys are experienced in helping providers protect their professional licenses following Medicare fraud allegations. Together, our team of Medicare fraud attorneys represent individuals with all issues related to Medicare fraud. Our comprehensive approach allows individuals charged with Medicare fraud to hire just one law firm to handle their civil and criminal Medicare fraud issues and subsequent licensure issues. This allows for cost-savings and helps promote a more knowledgeable and skilled defense to Medicare fraud allegations.  This approach allows for a strong defense by pooling together the knowledge and experience that our attorneys have obtained in specific areas of law, and allowing us to better protect the provider’s ability to practice in the future by ensuring that the criminal Medicare fraud case is handled in a manner that will aid in helping the provider resolve any subsequent licensing action or civil fraud action.

What is Medicare Fraud

Medicare fraud encompasses the false claims act, anti-kickback, Stark and health care fraud statutes. Medicare fraud is when an individual knowingly submits a false statement, or makes misrepresentations of fact, to obtain payment from a Federal health care program (Medicare, Medicaid or TRICARE) for which no entitlement would otherwise exist. Individuals who knowingly solicit, pay, and/or accept remuneration to induce or reward patient referrals for services or supplies reimbursed by a Federal health care program, may also be guilty of Medicare fraud. Additionally, making prohibited referrals for certain designated health services can also result in Medicare fraud.

Examples of Medicare Fraud

  • Submitting false claims to CMS for payment
  • Billing for services or supplies not provided
  • Ghost patients: submitting claims for services or supplies for a patient who does not exist or who the provider has no physician-patient relationship
  • Billing for services of such low quality that they are virtually worthless
  • Billing for durable medical equipment not legitimately prescribed by doctors
  • Unbundling: billing for tests or treatment separately where there is an ICD-10 procedure code that covers/bundles the services
  • Up-Coding: billing a higher code (CPT, ICD-10, E&M, HCPCS) than the service actually performed
  • Lack of medical necessity and overutilization: performing additional treatments or tests which are not clinically necessary
  • Duplicate billing
  • Utilization of excluded providers: submitting a claim on behalf of a provider that is ineligible to participate in Medicare and Medicaid
  • Non-Medicare participating providers billing patient more than 15% above Medicare fee schedule, when patient seeks reimbursement from Medicare
  • Making false statements on applications or contracts to participate Medicare or Medicaid program
  • Providing false or misleading information expected to influence a decision to discharge a patient
  • Violating Medicare assignment provisions or the physician agreement

Requirement for Medicare Fraud Conviction

Criminal Medicare fraud convictions require proof beyond a reasonable doubt that an individual knowingly and/or willfully submitted a false claim, or engaged in kickbacks or health care fraud. However, proof of actual knowledge or specific intent is not required to convict a person for Medicare fraud. A person can be convicted if they are found to have acted with deliberate ignorance or reckless disregard of the truth or falsity of the claim. In some Medicare fraud cases, the ultimate issue is simply whether the individual acted knowingly and/or willfully. In other cases, the issues are much more complex. For example, Medicare fraud allegations involving of worthless services, medical necessity or overutilization present an additional question regarding the standard of care. The current government trend is to criminally charge physicians who allegedly prescribe/perform health care services that are not medically necessary.  Our Medicare fraud attorneys are uniquely suited to defend these claims.  Our knowledge of conditions of payment, conditions of participation, and over 31 years defending physicians accused of malpractice, gives us the knowledge to understand and apply the standard of care, DRG’s, CPT’s, clinical practice guidelines, conditions of payment, etc. in the defense of our clients.

Medicare Fraud Related Charges

In addition to Medicare fraud defense, our Medicare fraud attorneys are experienced in defending charges related to Medicare fraud.

  • Attempt and Conspiracy to Commit: any person who attempts or conspires to commit any offense under the health care fraud chapter is subject to the same penalties for the prescribed offense
  • Forfeiture: Property alleged to be constituting or derived from any proceeds of unlawful activity, directly or indirectly, or property used or intended to be used in any manner or part to commit or facilitate the alleged Medicare fraud, may be subject to forfeiture.
  • Money Laundering: Using proceeds from unlawful activity to promote or conceal that activity, or engage in transactions greater than $10,000 derived from the alleged Medicare fraud.
  • Theft of Government Services: can include billing for services performed by a provider, vendor or entity excluded from the Medicare program. This includes indirect billings made by an employer or practice group for services performed on a Medicare beneficiary by an employee who is excluded from the Medicare program.
  • Wire Fraud: the use of electronic communication or telephone, in interstate communications made in furtherance of the alleged Medicare fraud.

Possible Medicare Fraud Sanctions

  • Restitution
  • Civil Monetary Penalties:
  • False Claims Act – up to $21,563 per claim and a fine three time the amount of damages sustained by the government as a result. Fine up to $250,000 if knowingly
  • Anti-Kickback Statute – up to $50,000 per violation and a fine three times the amount of the kickback
  • Health Care Fraud – up to $250,000
  • Exclusion Statute – up to $10,000 per item claimed while excluded and a fine three times the amount claimed
  • Jail Time:
  • Healthcare Fraud: up to 10 years. Up to 20 years if bodily injury
  • Conspiracy to Commit Healthcare Fraud and Fraud: up to 20 years
  • False Claims Act Convictions – up to 5 years per occurrence. Up to Life if convicted of multiple counts
  • Money Laundering: up to 10 years
  • Conspiracy to Commit Money Laundering: up to 20 years
  • Wire Fraud: up to 20 years
  • Other Sanctions and Collateral Consequences:
  • Loss of Licensure
  • Loss of DEA Registration
  • Exclusion from Medicare and Medicaid
  • Suspension of Payment on Outstanding Invoices
  • Loss of Staff Privileges
  • Loss of Employment

Experienced Medicare Fraud Attorneys

Early intervention of a skilled Medicare fraud attorney knowledgeable not only in criminal defense but health law is key. Medicare fraud prosecutions are highly specific prosecutions lead by the U.S. Attorney’s Health Care Fraud Division. Thus, defense of Medicare fraud allegations requires a highly specialized Medicare fraud defense team capable of analyzing a voluminous amount of health data with knowledge of billing practices, compliance issues, and medical necessity.

Our Medicare fraud attorneys defend individuals accused of Medicare fraud in Michigan, Florida, Idaho, Ohio and throughout the United States. We are located near the two major “Medicare fraud hotspots”, Miami and Detroit. If you have been arrested, charged or aware of an investigation into your practice regarding Medicare fraud, we encourage you to contact our Medicare fraud attorneys immediately for a free consultation.

Our Current Medicare Fraud Cases

Several home health agencies: alleged to have committed Medicare Fraud for improper referrals, performing services outside the plan of care, not having proper authorizations, not having proper re-certifications, etc.
Behavioral services agencies: alleged to have commit Medicare fraud for failure to use the proper CPT code resulting in allegations of fraudulent billing.
Compound pharmacies: We currently defend several individuals in multiple areas regarding compounding pharmacies. Generally, the allegation is that the pharmacy is “mining” patients through the use of a call center boiler room and the patients have no legitimate medical need for the compound, or the allegation is the compound serves no legitimate medical purpose and is no better than an over the counter medication or less expensive script.
Several physicians: charged with receiving remuneration of referring patients and for approving plans of care that were not medically necessary.
Medical directors: alleged to have committed Medicare fraud for receiving a salary or other payment, as well as referring patients to the program they currently work as the medical director.


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