Many health care practitioners participate in the federal Medicaid and/or Medicare program. If you are a practitioner who accepts Medicaid and/or Medicare, you must be aware of the numerous federal and state laws that are in place aimed at preventing fraud within those programs. A Murfreesboro criminal lawyer at Bennett, Michael & Hornsby discusses some of the ways in which a health care practitioner could be accused of Medicaid or Medicare fraud.
Medicaid and Medicare
Medicare is a healthcare program for the aged or disabled that is both funded and administered by the United States federal government through a Medicare tax imposed on both workers and employers. Medicaid is a healthcare program that is primarily funded by the United States government, although each state has the option to supplement funding as well. Moreover, each individual state administers its own Medicaid program, leading to disparities regarding eligibility requirements and benefits.
The Center for Medicaid and Medicare Services (CMS) defines Medicaid fraud as “the intentional providing of false information to get Medicaid to pay for medical care or services.” Examples of conduct that could be considered Medicaid fraud include:
- Billing for nonexistent services or equipment
- Overutilization of certain medical procedures or services
- Billing for unnecessary services or equipment
- Upcoding which involves billing at a higher level than the services justify
- Unbundling which involves using multiple billing codes when one code is sufficient
- Billing for the same treatment multiple times
- Knowingly treating someone who is using someone else’s Medicaid card
CMS further classifies conduct that constitutes Medicare fraud into one of the following three categories: false claims and misrepresentations, kickbacks, referrals.
Federal Medicaid and Medicare Fraud Laws
There are numerous complex federal laws that may apply to Medicaid and/or Medicare fraud. Three of the most utilized Medicaid/Medicare anti-fraud laws along with potential penalties include:
- False Claims Act (FCA). Any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government may face civil liability under the FCA. Specifically, you may be required to pay up to three times the amount of damages sustained by the Government because of the false claims, plus penalties up to $23,607 per false claim filed (as of 2021).
- Anti-Kickback Statute (AKS). It is a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward patient referrals or the generation of business involving any item or service reimbursable by a Federal health care program. If convicted, you face fines of up to three times the amount of the kickback plus civil fines of up to $50,000 per violation, criminal fines of up to $25,000 per violation and/or up to five years in prison, and exclusion from participation in the Federal health care program.
- Physician Self-Referral Law (Stark Law). A physician is prohibited from referring patients to an entity with which the physician or a member of the physician’s immediate family has a financial relationship for “designated health services” payable by Medicare or Medicaid. A violation of the Stark Law could result in civil fines for each violation, repayment of claims, and potential exclusion from participation in the Federal health care programs.
Tennessee Medicaid Fraud Laws
The State of Tennessee also has both a False Claims Act and a Medicaid False Claims Act. Modeled after the federal False Claims Act, the liability provisions of the Tennessee False Claims Act provide liability for any person who:
(1) Knowingly presents, or causes to be presented to an officer or employee of the state…, a false claim for payment or approval;
(2) Knowingly makes, uses, or causes to be made or used, a false record or statement to get a false claim paid or approved by the state or by any political subdivision;
(3) Conspires to defraud the state or any political subdivision by getting a claim allowed or paid by the state of by any political subdivision.
Liability under the Tennessee Medicaid False Claims Act applies to anyone who:
(A) presents, or causes to be presented to the state, a claim for payment under the Medicaid program knowing such claim is false or fraudulent;
(B) makes or uses, or causes to be made or used, a record or statement to get a false or fraudulent claim under the Medicaid program paid for or approved by the state knowing such record or statement is false;
(C) conspires to defraud the State by getting a claim allowed or paid under the Medicaid program knowing such claim is false or fraudulent.
A violation of the Tennessee False Claims and/or Medicaid False Claims Act can potentially subject a practitioner to treble damages and civil penalties.
Contact a Murfreesboro Criminal Lawyer
If you have been charged with Medicaid or Medicare fraud in Tennessee, consult with an experienced Murfreesboro criminal lawyer as soon as possible to discuss your legal options. In Tennessee contact a Murfreesboro criminal lawyer at Bennett, Michael & Hornsby to discuss your legal options. Contact the team today by calling 615-898-1560 to schedule your free appointment.