As a federal crime, Medicare fraud is investigated by the Medicare Fraud Strike Force. It is comprised of federal investigators and prosecutors from various agencies. Examples include:
- U.S. Department of Health and Human Services, Office of the Inspector General (HHS-OIG);
- Department of Justice (DOJ);
- Drug Enforcement Administration (DEA);
- Department of Defense (DOD);
- Internal Revenue Service (IRS); and
- Federal Bureau of Investigations (FBI)
Depending on the case, the feds also enlist the help of state and local law enforcement. An example is the Nevada Attorney General’s Office. It runs the Medicaid Fraud Control Unit (MFCU).
What is Medicare fraud?
There are many types of Medicare fraud. A common type involves medical providers filing a fraudulent claim in violation of the False Claims Act. Examples include:
- Submitting a claim for medically unnecessary services, equipment, supplies, or certification (such as for hospice or home health care);
- Phantom-billing (billing for services that never occurred);
- Up-coding; or
- Inflating charges
Medicare fraud also comprises:
- Accepting kickbacks (in violation of the Anti-Kickback Law); or
- Physician self-referrals (in violation of the Stark Law)
Las Vegas has a particularly high number of people on Medicare or Medicaid. So the feds are closely monitoring claims coming out of Nevada.
What are the criminal penalties for Medicare Fraud?
Under 18 U.S.C. § 1347, Medicare fraud carries up to 10 years in Federal Prison. But it becomes up to 20 years if a patient sustained serious bodily injury. And if a patient died, the court can sentence the defendant to life.
Other possible punishments include high fines.
What are the civil penalties for Medicare Fraud?
Under 31 U.S.C. § 3729-3733, civil penalties include:
- Up to $11,000 in fines per false claim;
- Treble damages;
- Attorney Fees; and/or
- Exclusion from federal health care programs.
Defendants may also lose their professional licenses.
What are the defenses to Medicare Fraud?
A common defense is that the defendant had no intent to defraud. Perhaps the false claim stemmed from incompetent medical staff. Or perhaps the defendant was following outdated laws.
Sometimes, the government is at fault. The HHS is a large bureaucracy that makes mistakes as well. Perhaps they attributed a false claim to an innocent provider when the government itself made a clerical error.
Other times, the government may flag something as a false claim that is in fact lawful. But it may take a criminal defense attorney to show the government that the defendant did nothing wrong.
Can health care fraud be a state crime?
Yes. Health care fraud (NRS 686A.2715) is typically a category D felony in Nevada. It carries:
- 1 – 4 years in Nevada State Prison, and
- Up to $5,000 in fines (at the judge’s discretion).
In addition, the court can order the defendant to pay full restitution. And depending on the case, the defendant may lose his/her professional license. (Learn more about Medical Board license disciplinary procedures in Nevada.)
Nevada health care fraud convictions can usually be sealed from the defendant’s record five years after the case ends. But if the case gets dismissed, the record may be sealed right away.
Health care fraud is also deportable. So non-citizens convicted of it could face removal from the U.S.