Medicare / Medicaid Fraud - FAQs

We frequently receive questions about Medicare and Medicaid fraud under State and Federal Law. In an effort to help you obtain as much information as possible, we have compiled those that we think are the most commonly asked questions. We have represented a wide range of clients relating to Medicare/Medicaid fraud investigations, including Targeted Case Management officers (TCMs) and owners of multi-million dollar health care clinics. He also has experience in handling cases that targeted licensed health care professionals. Please feel free to browse through them and contact us directly if you need more information.


What can be constituted as Medicare Fraud?

Medicare is a federal program attached to Social Security. It is available to all U.S. citizens 65 years of age or older and it also covers people with certain disabilities. It is available regardless of income.Back to FAQs

What can be constituted Medicaid Fraud?

Medicaid is a public assistance program based largely on financial need. Medicaid is a joint federal and state program that helps low-income individuals and families pay for the costs associated with medical and long-term custodial care. Unlike Medicare, a program largely standardized by the federal government, state and local governments administer Medicaid using federal guidelines. Each state can shape the program to its individual needs. Because of this federal/state partnership, there are actually 50 different Medicaid programs, one for each state.Back to FAQs

Which are some examples of Medicare/Medicaid fraud?

Types of Medicaid/Medicare fraud include:

  • Billing for services not rendered.
  • Billing for a non-covered service as a covered service.
  • Misrepresenting dates of service.
  • Misrepresenting locations of service.
  • Misrepresenting provider of service.
  • Waiving of deductibles and/or co-payments.
  • Incorrect reporting of diagnoses or procedures (includes unbundling).
  • Overutilization of services.
  • Corruption (kickbacks and bribery).
  • False or unnecessary issuance of prescription drugs.

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Which are the penalties for Medicaid/Medicare fraud?

The penalties for Medicare/Medicaid fraud can be very harsh. They often involve multiple offenses and these can often charged at both federal and state levels. Some of the possible laws and penalties include:

  • Imprisonment: The prison sentence at federal level varies depending on how much money was involved.
  • Fines: Federal convictions carry fines equal or up to twice as much the actual loss. Individuals carry a fine of $250,000 and corporations carry a fine of up to $400,000, whichever is greater.
  • Medical sanctions: Providers, including physicians, are likely to lose their professional license and can be barred from any future contracts with Medicare/Medicaid for life.
  • Multiple counts: Every single false claim is an individual offense. If dozens or hundreds of billings have been done fraudulently, maximum sentences can be requested.
  • Racketeering/RICO prosecutions: Additional criminal penalties can be carried if fraud falls under RICO, as well as forfeiture of assets.
  • Civil lawsuits: Some fraud offenses can also be sued under RICO civilly, which can lead to triple damages.

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Who investigates Medicaid fraud?

The Florida Attorney General’s Medicaid Fraud Control Unit (MFCU) investigates and prosecutes fraud involving providers that intentionally defraud the state's Medicaid program through fraudulent billing practices. The MFCU investigates a wide range of misconduct originating primarily from fraudulent billing schemes. The most common schemes involve doctors, dentists, clinics and other health care providers billing for services never performed, over billing for services provided, or billing for tests, services and products that are medically unnecessary.Back to FAQs

Who investigates Medicare fraud?

The Office of Inspector General for the U.S. Department of Health and Human Services is tasked with protecting the integrity of Department of Health and Human Services (HHS) programs, to include Medicare and Medicaid programs, as well as the health and welfare of the beneficiaries of those programs. The Office of Investigations for the HHS, OIG collaboratively works with the Federal Bureau of Investigation in investigating Medicare Fraud.Back to FAQs