Healthcare professionals, Medicare fraud and the False Claims Act

On Behalf of | Nov 15, 2021 | Fraud, Healthcare Fraud

There are many ways of defrauding the federal government, whether by an individual or an organized group.

Suspected Medicare fraud triggers investigations under the False Claims Act and several related laws, which exist to protect the government.

Recognizing Medicare fraud

Medicare is a heavily regulated system. It is also complex, which enables fraudsters to attempt profiting from the system in various ways:

– submitting false claims or misrepresenting facts to obtain a healthcare payment

– billing Medicare for appointments patients do not keep

– billing for healthcare services that were not furnished

falsifying records to show delivery of medical equipment never received

– soliciting payment for referrals for services reimbursed by Medicare

Understanding the FCA

The False Claims Act (FCA) is one of several federal fraud laws that apply to doctors. Several government agencies including the Department of Justice and the Centers for Medicare & Medicaid Services enforce the laws. Those who file false claims with Medicare or Medicaid face fines equal to three times the loss plus $11,000 for each claim filed. Under the FCA, any one item or service billed constitutes a single claim, so the fines multiple quickly. The FCA also supports a whistleblower provision that allows the whistleblower to collect a portion of any funds recovered.

Anticipating an investigation

Through a routine administrative audit or other means, a healthcare professional may learn that an investigation for Medicare fraud is imminent. This is the time to rely on legal guidance and representation. An effective defense strategy is essential in the effort to protect rights and preserve a career.


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