Medicare and Medicaid Fraud Defense

The Centers for Medicare and Medicaid Services has cracked down on tens of thousands of healthcare providers suspected of healthcare fraud in recent years. In 2013 alone, the U.S. government recovered $4.3 billion through its healthcare fraud prevention and enforcement efforts.

From pharmaceutical and device manufacturers to hospitals and physicians, the healthcare industry is one of the most regulated in the nation.

Nationally, there are three important federal laws about which healthcare providers must be aware: The False Claims Act, the Physician Self-Referral Law, better known as the Stark Law; and the Anti-Kickback statute.

The False Claims Act is the federal governments primary tool in the battle against fraudulent claims. Simply stated, it prohibits the submission of knowingly false claims to collect federal money. These can include fraudulent billing such as charging government payors for services not rendered; billing for medically unnecessary services; falsifying records; or upcoding i.e. submitting a claim for healthcare services that represent a expensive procedure than what was performed, among others. Under this act, healthcare professionals and others can be liable for treble damages, plus civil penalties.

The Stark Law prohibits a physician from making referrals for certain designated services payable by Medicare to an entity with which the provider, or an immediate family member has a financial interest, unless an exception applies.

The Anti-Kickback Statute is a criminal statute that prohibits the exchange, or the offer to exchange, anything of value in an effort to induce or reward the referral of federal healthcare program business.

In Florida, healthcare providers also must be aware of the Florida Patient Self-Referral Act of 1992 and the Florida Patient Brokering Act.

Florida’s Patient Self-Referral Act was modeled after the federal law, although it has not been updated over the years as the federal law has. The state’s Patient Brokering Act is a criminal statute that prohibits any healthcare provider or health care facility from giving or receiving any form of remuneration in exchange for referrals, regardless of the source of payment for the applicable service or product.

Because of the high number of healthcare claims submitted to insurers, the government doesn’t have the resources available to effectively catch everyone who is breaking the law. But that doesn’t mean such crimes go undetected. Whistleblowers play a big part in the battle against healthcare fraud and can bring it to the government’s attention by filing a qui tam lawsuit on behalf of the government.

We represent healthcare professionals in state and federal court who are charged with fraudulent billing, kickbacks, Medicare and Medicaid fraud and false claims, among others.

Ignorance is not a defense in today’s healthcare environment. Our team of highly skilled attorneys and consultants are here to help you before you become the focus of an investigation and will aggressively defend you should you become the target of one.

Material presented on the Health Law Offices of Anthony C. Vitale's website is intended for information purposes only.

It is not intended as professional advice and should not be construed as such.