Medicare / Medicaid Fraud
Medicare and Medicaid are two very sizeable federal health care programs that provide coverage to millions of Floridians and other Americans. The sample size and scope of the programs make them ripe for instances of health care fraud, and the federal government invests heavily in uncovering and prosecuting instances of alleged fraud involving Medicare or Medicaid.
People who are accused of Medicare or Medicaid fraud not only face serious criminal penalties that can include lengthy terms of imprisonment, but they can also be ordered to pay significant civil monetary penalties that may be hundreds of thousands of dollars. Most Medicare or Medicaid fraud charges typically involve alleged violations of one or more of four federal statutes.
Were you arrested or do you think that you might be under investigation in South Florida for an alleged Medicare or Medicaid fraud offense? Do not say anything to authorities without first contacting The Hoffman Firm.
Miami criminal defense lawyer Evan A. Hoffman defends clients in Key Biscayne, Miami, Coral Gables, Hialeah, North Miami, Aventura, Opa-Locka, South Miami, and many surrounding areas of Miami-Dade County. Our attorney can provide a complete evaluation of your case as soon as you call (305) 249-0090 to schedule a free, confidential consultation.
Overview of Medicare/Medicaid Fraud in North Miami
- How might a person be punished for false or fraudulent claims?
- What constitutes a kickback?
- How does the Stark law work?
- Are there other violations that can result in civil penalties?
- Where can I find more information about Medicare/Medicaid fraud in Miami-Dade County?
False Claims Act (31 U.S.C. § 3729)
The federal government is allowed to recoup damages under the False Claims Act (FCA) from any individual (including organizations, agencies, or other entities) receiving payment from the federal government for false or fraudulent Medicare or Medicaid claims. Liability under the FCA includes committing or conspiring to commit any of the following acts:
- Knowingly presenting, or causing to be presented, a false or fraudulent claim for payment or approval
- Knowingly making, using, or causing to be made or used, a false record or statement material to a false or fraudulent claim
- Having possession, custody, or control of property or money used, or to be used, by the government and knowingly delivering, or causing to be delivered, less than all of that money or property
- Being authorized to make or deliver a document certifying receipt of property used, or to be used, by the government and, intending to defraud the Government, making or delivering the receipt without completely knowing that the information on the receipt is true
- Knowingly buying, or receiving as a pledge of an obligation or debt, public property from an officer or employee of the government, or a member of the Armed Forces, who lawfully may not sell or pledge property
- Knowingly making, using, or causing to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the government, or knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay or transmit money or property to the government
A conviction may result in criminal penalties that can include up to five years in prison and fines. Alleged offenders also face civil monetary penalties (CMP) of $11,000 per claim filed plus up to three times the amount of damages the government sustains as well as the costs of bringing the civil action.
Anti-Kickback Statute (42 U.S.C. § 1320a–7b)
Knowingly and willfully soliciting or receiving any remuneration directly or indirectly, overtly or covertly, in cash or in kind, in exchange for referrals or the generation of business involving any item or service payable by Medicaid or Medicare is prohibited under the Anti-Kickback Statute (AKS).
A violation is punishable by criminal penalties such as fines of up to $25,000 per violation and up to five years in prison for each violation, as well as CMPs of up to $50,000 per violation and up to three times the amount of the alleged kickback.
Physician Self-Referral Law (42 U.S.C. § 1395nn)
More commonly known as "the Stark law," physicians are prohibited under this statute from making patient referrals to entities with which the physician or an immediate family member has a financial relationship for “designated health services” paid by Medicare or Medicaid. The phrase designated health services is defined as including any of the following:
- Clinical laboratory services
- Physical therapy services
- Occupational therapy services
- Radiology services, including magnetic resonance imaging, computerized axial tomography scans, and ultrasound services
- Radiation therapy services and supplies
- Durable medical equipment and supplies
- Parenteral and enteral nutrients, equipment, and supplies
- Prosthetics, orthotics, and prosthetic devices and supplies
- Home health services
- Outpatient prescription drugs
- Inpatient and outpatient hospital services
- Outpatient speech-language pathology services
The Physician Self-Referral Law is a strict liability statute, which means that a prosecutor does not have to prove that an alleged offender had a specific intent to violate the law. Violations are punishable by CMPs of up to $15,000 per service, civil assessments of to three times the amount claimed, and possible orders to refund full amounts for all services referred.
Civil Monetary Penalties (42 U.S.C. § 1320a-7a)
The Office of Inspector General (OIG) is also authorized to seek CMPs ranging from $10,000 to $50,000 per violation for any of the following offenses relating to improperly filed claims:
- Failing to grant timely access, upon reasonable request, to the Inspector General of the Department of Health and Human Services (HHS), for the purpose of audits, investigations, evaluations, or other statutory functions of the Inspector General of the Department of HHS
- Knowingly making or causing to be made any false statement, omission, or misrepresentation of a material fact in any application, bid, or contract to participate or enroll as a provider of services or a supplier under Medicaid or Medicare
- Knowing of an overpayment and not reporting and returning the overpayment
The OIG can also seek CMPs ranging from $2,000 per individual to three times the amount of payments made to the alleged offender for payments made, directly or indirectly, to induce reduction or limitation of services.
Florida Medicare/Medicaid Fraud Resources
Florida Attorney General | Medicaid Fraud Control Unit (MCFU) — The Attorney General’s MCFU "investigates and prosecutes fraud involving providers that intentionally defraud the state's Medicaid program through fraudulent billing practices." Use this website to view an MCFU brochure. The brochure discusses reporting suspected fraud or abuse.Office of the Attorney General
444 Brickell Avenue, Suite 650
Miami, FL 33131
Medicare Fraud Strike Force | Office of Inspector General | U.S. Department of Health & Human Services (HHS) — Miami is home to one of nine Medicare Fraud Strike Force Teams that "prevent and combat health care fraud, waste, and abuse" in schemes across the nation. Visit this website to learn more about the latest strike force enforcement actions. You can also visit the Miami Strike Force Operations website to find more information about prominent cases.
If you believe that you could be under investigation or you were already arrested for a Medicare or Medicaid fraud crime in Miami-Dade County, it is in your best interest to immediately retain legal counsel. The Hoffman Firm represents individuals in communities all over South Florida, including Miami Beach, Coral Gables, Homestead, Hialeah, Doral, Aventura, North Miami, South Miami, Key Biscayne, and several others.
Evan A. Hoffman is an experienced criminal defense attorney in Miami who can work to help you achieve the most favorable outcome to your case that results in the fewest possible consequences. He can review your case and discuss all of your legal options when you call (305) 249-0090 or fill out an online contact form to schedule a free initial consultation.