Medical Law

Fraud is well-defined as making untruthful statements or representations of material facts to obtain some benefit or payment for which no entitlement would otherwise exist. These acts may be committed either for the person’s own benefit or for the benefit of some other party. In other words, fraud includes the obtaining of something of value through misrepresentation or concealment of material facts. Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced.

It is a crime to defraud the Federal Government and its programs. Punishment may involve imprisonment, major fines, or both. Criminal penalties for health care fraud reflect the serious harms associated with health care fraud and the need for aggressive and appropriate fraud prevention. In some states, providers and health care organizations may lose their licenses. Convictions also may result in exclusion from Medicare participation for a specified length of time. Medicare fraud may also result in civil liability. Both fraud and abuse can expose providers to criminal and civil liability. An example of Medicare fraud can include, knowingly altering claims forms and/or receipts to receive a higher payment amount. Examples of Medicare abuse are misusing codes on a claim, charging excessively for services or supplies, and billing for services that were not medically necessary.

The False Claims Act, Anti-Kickback Statute, Physician Self-Referral Law (Stark Law), Social Security Act, and the U.S. Criminal Code are used to address fraud and abuse. Violations of these laws may result in nonpayment of claims, Civil Monetary Penalties (CMPs), exclusion from the Medicare Program, and criminal and civil liability. Penalties range from up to $10,000 to $50,000 per...