Healthcare Fraud is:
“knowingly and willfully executing, or attempting to execute, a scheme or artifice
(1) to defraud any health care benefit program; or
2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health benefit program.”
Healthcare fraud can result in civil and criminal penalties that include fines, monetary damages, and even imprisonment. Additionally, there is a penalty of up to 20 years in prison or life in prison if the violation resulted in a person’s death. 18 U.S.C. §1347
Links & Resources
CA Health Advocates.org:
- Medicare Fraud: An Overview
- How to Stop & Report Medicare Fraud
- Senior Medicare Patrol (SMP) Project
Serving as the umbrella for a variety of CMS education and communication activities, the MLN offers:
The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health & Human Services (HHS).
Waste includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Compliance Education Materials: Compliance 101
Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training
OIG’s Provider Self-Disclosure Protocol
Part C and Part D Compliance and Audits – Overview
A Roadmap for New Physicians: Avoiding Medicare Fraud and Abuse
Safe Harbor Regulations
CA Health Line 7.19.2017 Fraud & Billing mistakes in Medicare Advantage plans ran $16B in 2016, if you include standard Medicare $60B.
Orange County Register: Brea Man Gets Decade In Prison In $2.9 Million Dollar Medicare Fraud
A Brea man who used his rehabilitation clinics to submit millions of dollars in false Medicare claims was sentenced this week to more than a decade in federal prison, even as he awaits sentencing in a second health care fraud case. U.S. District Judge David O. Carter, during a hearing at the federal courthouse in Santa Ana, ordered Simon Hong on Monday to spend 121 months behind bars and to pay nearly $3 million in restitution, according to the U.S. Department of Justice. (Emery, 1/10)
Aetna wins $37.4 M civil judgement for fraudulent bills from Bay Area Surgical Management Learn More===> Mercury News 4.21.2016
Indictments – a doctor at the clinic documented evaluations that never happened, while staff falsified records to justify surgeries, some of which were unnecessary. Further, the indictment said some surgeries were performed by a physician’s assistant who had not attended medical school and was not overseen by a surgeon during the procedures. Although the patient victims sustained physical harm, we who pay higher premiums for health care suffer economic harm when scams are allowed to continue unchecked” (Winton/Hamilton, “L.A. Now,” Los Angeles Times, 9/15). CA Healthline 9.16.2015
Durable Medical Equipment Fraud – LA Times 9.4.2015
Nearly 250 people, including 46 providers, were charged with falsely billing Medicare a total of nearly $712 million – Medicare Fraud Strike Force, which has charged more than 2,300 people accused of falsely billing Medicare more than $7 billion since it was established in 2007 —
federal officials charged:
- Three owners of a hospice service in Detroit who allegedly paid kickbacks for referrals from two physicians who wrote medically unnecessary prescriptions;
- Two home health care companies in New Orleans that allegedly billed Medicare $38 million for glucose monitors they sent to patients regardless of medical need; and
- Administrators of a mental health center in Miami that allegedly paid kickbacks to owners of assisted living facilities and patient recruiters (Department of Justice release, 6/18). CA Health Line 6.19.2015
More than 44 of the 243 suspects allegedly defrauded Medicare Part D, marking the first major crackdown on fraud of the prescription drug benefits program for seniors.
Related Web Pages
Medical Necessity rules & definition
Our Webpage on Fraud in General
- Department of Health and Human Services Office of Inspector General
- CMS compliance guidance for MA and Part D plans
- Definitions of fraud, waste, and abuse can be found in Medicare Managed Care Manual (MMCM) Chap.21 Sec.20 Definitions