A Primer on Medicare Fraud

For as long as Medicare and Medicaid have been around, fraudsters have been finding ways to fraudulently obtain those federal funds. In 2019, the two programs—along with CHIP and ACA subsidies—made up nearly one-quarter of the federal budget. In light of those two conditions, it’s not surprising that federal agencies pursue allegations of Medicare and Medicaid fraud quite aggressively. A variety of federal and state laws make up the basis of health care fraud enforcement efforts. 

Anti-Kickback Statute

The federal anti-kickback statute and the Texas Patient Solicitation Act target health care professionals who funnel patients to a particular facility or physician’s practice in exchange for remuneration (money). For example, an internist would be blatantly violating anti-kickback laws for sending patients to an allergist if those patients did not truly have problems with allergies. There are many ways that an illegal kickback arrangement can be implemented. 

In November 2020, a Houston-area physician was sentenced to five years in federal prison for multiple health care fraud charges. Besides getting convicted for two counts of making false statements, the doctor was also convicted of conspiracy to commit heath care fraud and conspiracy to receive health care kickbacks. The doctor received kickbacks by paying “patients” to receive medically unnecessary products and services, which resulted in millions of dollars being fraudulently billed to Medicare. The doctor also required home health agencies to pay her kickbacks, which she disguised as a “co-pay.”

Billing For Unnecessary Services

The unique circumstances surrounding the COVID-19 pandemic produced ample opportunity for heath care fraudsters. It can be quite difficult to monitor telehealth services, which exploded in popularity during the pandemic. Just a few weeks ago, 14 defendants were charged with a litany of crimes arising from alleged health care fraud committed during the pandemic. Besides numerous charges of receiving kickbacks, a number of the defendants were charged with billing Medicare and Medicaid for unnecessary services. 

One way defendants were alleged to have ordered unnecessary services (which included genetic cancer tests and various respiratory tests) was by using information obtained after patients submitted COVID-19 tests. The defendants were alleged to have targeted seniors in residential care facilities and, in many cases, did not even notify victims of their COVID-19 test results.

COVID-19 Fraud Is Still Being Aggressively Investigated

It seems like we are getting a better picture of the federal government’s strategy of going after suspected fraudsters. Traditional ways of defrauding Medicare and Medicaid are still as prevalent as they ever were, but the pandemic opened up new opportunities for health care fraud. 

As soon as you think you are under investigation for Medicare or Medicaid fraud, you need to promptly contact an experienced attorney. Attorney Charles Banker has spent decades defending clients charged with federal and state crimes. Contact us today to get started on a premium defense; your first consultation with our team is free.

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The Law Offices of Charles A. Banker, III

Our firm’s founder, Charles A. Banker III, has been a solo criminal defense practitioner with offices in Houston and McAllen, TX for over 30 years. He understands what it means to work independently in today’s hyperconnected world, but he also knows that sometimes you need to lean on others.

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