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Facing Medicare/Medicaid fraud charges as a health professional?

When people talk about Medicaid and Medicare fraud, there's commonly a focus on people receiving benefits that they should not receive, given their income or other factors. While individual acts of fraud can cost quite a bit of money, Medicaid and Medicare fraud involving medical providers and companies can cost so much more.

Medicare, Medicaid and other government programs are notoriously difficult to navigate, especially when the regulations change periodically due to the actions of Congress or the New Jersey state legislature. Therefore, it's possible for individual medical professionals or even entire healthcare organizations to suddenly find themselves accused of Medicare or Medicaid fraud. And the costs of conviction could easily climb into the tens or hundreds of thousands of dollars.

Common forms of Medicaid and Medicare fraud

All doctors take an oath to put the well-being of their patients above all else. Some of the most common errors that lead to Medicaid or Medicare fraud are innocent mistakes as opposed to deliberate intentions to defraud the government. Such mistakes include:

  • Ordering the wrong procedures or prescriptions based on a misdiagnosis or chart error
  • Billing services for the wrong patient
  • Ordering additional tests or procedures that go beyond standard practice at the insistence of the patient or patient's family member

Of course, there are those who do attempt to game the system. There was a recent case of dental Medicaid fraud that involved a dentist removing healthy teeth from young children to make money. Another well-known tactic used by some is to bill for services that were never rendered, including visits with patients who were actually no-shows.

Medical financial fraud is a serious crime

The penalties of a federal fraud crime are quite steep, regardless of what the alleged fraudulent activity was. If you've been accused of medical fraud, you could face a combination of jail time and steep fines, as well as the seizure of any assets purchased with allegedly fraudulent funds.

Many times, Medicare/Medicaid fraud is also construed as a violation of the Hippocratic Oath that most medical practitioners take when getting licensed. Thus, penalties for conviction mean losing the right to practice medicine for a specific amount of time or, in extreme cases, for the rest of your career. Combine that with jail time, fines, loss of assets and income - not to mention the damage to your reputation - and it's easy to see how fraud charges can quickly spiral out of control.

Workers also have an obligation to report fraud

Nurses, other doctors and even billing professionals are legally obligated to report suspected fraud, like any other crime. There are systems in place that allow people to make these claims anonymously or even compensate those who report suspected fraud, if the fraud ends up substantiated by an investigation.

Failing to report behaviors that seem to indicate fraud, such as changing diagnoses or procedure codes, or billing for services not performed, could result in accessory or even conspiracy charges, depending on the scope of the fraud and how aware someone was of what was happening.

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