Medicaid fraud and abuse are some of the most severe allegations a business can face, and the federal government has taken a firm stance on fighting such cases. More than ever, proofing your business against potential fraud and abuse allegations is a good idea. If you are worried about your company’s ability to defend a fraud allegation or just want to cover your bases, Norman Spencer Law Group can help. Our team of attorneys has handled a wide range of healthcare cases, including Medicaid fraud defense and consultation.
What is Medicaid Fraud and Abuse?
Before going into how to safeguard your business from Medicaid fraud, it is important to know what kind of actions constitute fraud and abuse. Fraud is any intentional deception intended to cause unauthorized benefit, and abuse is any practice inconsistent with proper fiscal and medical business practices.
These practices result in unnecessary costs for the Medicaid program, cause reimbursements for unneeded medical services, or fail to meet recognized healthcare standards. Several groups can commit fraud and abuse, including:
- Managed Care Organizations
- Contractors and Subcontractors
- Healthcare Providers
- State Employees
- Medicaid Beneficiaries and Managed Care Enrollee
There are also many ways that Medicaid fraud and abuse can be committed. These include:
- Billing for unprovided services
- Misusing medical codes
- Billing for unneeded services
- Charging for exessive or unneeded medical supplies
- Billing for appointments that patients fail to keep
Medicaid Fraud Defense – Laws to Know
On top of the types of fraud and abuse your organization could face, there are many laws that must be followed. Federal and state laws cover Medicaid fraud, but the most important federal laws include:
The False Claims Act (FCA): The FCA is a federal law that protects the government from being overcharged or charged for inferior goods and services. No actual intent to defraud the government is required to trigger an FCA claim. Acting in a way that proves knowledge of a false claim or working with deliberate ignorance is enough.
Anti-Kickback Statute: This federal law makes it a crime to knowingly and willfully pay or receive remuneration – directly or indirectly – to cause or benefit from patient referrals. This also applies to any business involving items and services that federal healthcare programs can reimburse.
Stark Laws: Stark laws, also known as physician self-referral laws, are federal laws that forbid a physician from referring a patient to Medicare or Medicaid reimbursable services via a group through which the physician or the physician’s immediate family members are associated.
Criminal Healthcare Fraud Statute: A federal law forbids going through with or attempting a scheme to interfere with the delivery or payment of healthcare benefits and services. This includes attempts to defraud a healthcare benefit program or deceitfully obtain money owned by any healthcare benefit program.
Exclusion Statute: This federal law allows the Office of Inspector General (OIG) to exclude any healthcare provider from healthcare benefit programs for committing Medicaid fraud, abusing or neglecting patients, or felony convictions surrounding healthcare laws. This statute can also be triggered by any of the above regulations, misdemeanor charges, license suspensions, or revocation.
Civil Monetary Penalties Law (CMPL): This federal law allows the OIG to charge damages and sometimes exclude a provider from a national healthcare benefits program. Different penalties can be imposed based on the types of violations, up to a maximum of three times the amount claimed for a service. Much like the Exclusion Statute, the above laws can trigger this penalty.
Steps to Properly Defend Your Business
The first step to protecting your business from Medicaid fraud allegations is to ensure you and your employees are aware of all the types of fraud that apply. Knowing what groups can be involved and how they might commit fraud or abuse is essential. Another crucial step is to be aware of the major federal laws that deal with Medicaid fraud and abuse. Updating your business on federal and state legislation can make a difference in borderline cases.
Finally, knowing a healthcare attorney with Medicaid fraud defense experience goes a long way. Building this relationship is vital since a lawyer can help prevent you from being caught in the middle of a fraud case in the first place. A Medicaid fraud attorney can also help look at your business’s financials, claims, and employee records to ensure nothing is amiss. Your lawyer will be ready to defend you if something does come up.
Norman Spencer Law Group has a dedicated team of healthcare fraud and abuse lawyers with the expertise you can count on. If you have questions about protecting your business, want to consult with an expert, or find yourself in the middle of a Medicaid fraud allegation, call us. We can set up a free consultation over the phone, via ZOOM, email, or in person.