Medicare / Medicaid Fraud
Annual spending by the state of Florida on health care programs runs into the tens of billions of dollars. At the federal level, the U.S. government budget for combined Medicare and Medicaid hovers near $1 trillion. Fraud in these programs is targeted by state and federal prosecutors.
The accused in these cases are typically healthcare professionals who have no experience being in trouble with the law. Doctors, clinics, billing services, dentists, physical therapists, and other healthcare owners or employees may be investigated, indicted, or otherwise involved in a case of Medicaid fraud or Medicare fraud. If you believe you are under investigation for billing practices, contact a criminal defense attorney experienced in financial crimes right away.Jacksonville Medicaid Fraud Lawyer
An indictment forhealth care fraud can severely hinder your business, even if you are eventually found not guilty. For the time period a care provider is under an indictment, their participation in Medicaid or Medicare will be suspended. Call us at (904) 354-0333 if you have reason to suspect you are under investigation for fraud in Northeast Florida. Roelke Law will be proactive in your case and may be able to resolve the issue with the investigators or prosecutors before charges are filed.
Attorney William Roelke practices law in both Florida and federal court, representing clients across Jacksonville, Atlantic Beach, Neptune Beach, Penney Farms, Fernandina Beach, Hilliard, and other surrounding communities.
Duval County Medicaid Fraud Overview
- Which actions are considered fraud by a Medicaid provider?
- How does a person commit Medicare fraud?
- What are the consequences of a conviction?
- Are there federal laws relating to this offense?
A Medicaid provider that attempts to defraud the Florida Agency for Health Care Administration, the outfit overseeing Florida’s Medicaid system, stands to be charged under Florida Statute § 409.920. Common schemes include phantom billing, up-coding, over billing, or billing for non-essential tests and service.
The law stipulates that a person may not:
- Knowingly make, cause to be made, or aid and abet in the making of any false statement or false representation of a material fact, by commission or omission, in any claim submitted to the agency or its fiscal agent or a managed care plan for payment.
- Knowingly make, cause to be made, or aid and abet in the making of a claim for items or services that are not authorized to be reimbursed by the Medicaid program.
- Knowingly charge, solicit, accept, or receive anything of value, other than an authorized copayment from a Medicaid recipient, from any source in addition to the amount legally payable for an item or service provided to a Medicaid recipient under the Medicaid program or knowingly fail to credit the agency or its fiscal agent for any payment received from a third-party source.
- Knowingly make or in any way cause to be made any false statement or false representation of a material fact, by commission or omission, in any document containing items of income and expense that is or may be used by the agency to determine a general or specific rate of payment for an item or service provided by a provider.
- Knowingly solicit, offer, pay, or receive any remuneration, including any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind, in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made, in whole or in part, under the Medicaid program, or in return for obtaining, purchasing, leasing, ordering, or arranging for or recommending, obtaining, purchasing, leasing, or ordering any goods, facility, item, or service, for which payment may be made, in whole or in part, under the Medicaid program.
- Knowingly submit false or misleading information or statements to the Medicaid program for the purpose of being accepted as a Medicaid provider.
- Knowingly use or endeavor to use a Medicaid provider’s identification number or a Medicaid recipient’s identification number to make, cause to be made, or aid and abet in the making of a claim for items or services that are not authorized to be reimbursed by the Medicaid program.
Those seeking services from the Florida Agency for Health Care Administration as patients may also find themselves involved in a prosecution if the government believes them to be untruthful in their applications or illegally selling subsidized prescription drugs.
It is illegal to knowingly sell, knowingly attempt or conspire to sell, or knowingly cause another person to sell prescription drugs acquired through the Medicaid program. The same punishment applies to those who are illegally seeking to purchase Medicare subsidized prescription drugs.
Florida will also prosecute an individual who knowingly makes or knowingly causes to be made, or who attempts or conspires to make, any false statement or representation to any person for the purpose of obtaining goods or services from the Medicaid program.
The Florida Medicaid Fraud Unit investigates Medicaid fraud before passing on their work to a prosecutor for a formal indictment. If convicted, the sentence is determined by the size of the fraud, but in every case a first offense is a felony.
If the amount that a Medicaid provider receives $10,000 or less, the sentence will be a felony of the third degree. The penalty is up to five years imprisonment. For a scheme involving more than $10,000, but less than $50,000, the penalty will be a felony of the second degree. A second degree felony may be punished by a prison term of 15 years. A fraud raking in more than $50,000 is a felony of the first degree with a prison sentence up to 30 years. A fine may be applied up to five times the value of the fraud.
With individuals who attempt to defraud the government, the penalties will follow according to the value of the prescription drugs or services stolen.
- Less than $20,000 – Felony of the third degree
- $20,000 or more, but less than $100,000 – Felony of the second degree
- $100,000 or more – Felony of the first degree
Some of the multiple federal laws and regulations relating to fraud in the Medicaid or Medicare programs include:
18 U.S.C. § 287 – False Claims Act
A healthcare provider may not knowingly submit false, fictitious, or fraudulent claims to the federal government under the Medicaid or Medicare programs. Again, the most common schemes are over billing for services provided, billing for services that are not medically essential, billing for a more expensive procedure than the one provided, and billing for services that were never performed. A felony conviction may carry up to five years in federal prison and a massive fine up to $250,000 for an individual and $500,000 for a corporation. A misdemeanor conviction may result in a fine up to $100,000 for an individual and $200,000 for a corporation.
18 U.S.C. §1001 - False Statements Act
It is illegal for a healthcare provider to make any false or fraudulent statement to the federal government that would materially shape the decision of whether or not to reimburse for the services provided. The healthcare provider must have committed the act willfully and knowing the statement to be false. The penalty for making a fraudulent statement is up to five years in federal prison and a maximum $100,000 fine. Each time a false statement was made, whether by marking up the cost of equipment or submitting a false document, there can be a new charge under the False Statements Act. The charges can obviously swell to the point where a defendant is facing many years in prison and many tens of thousands of dollars in fines.
18 U.S. Code § 1347 - Health Care Fraud
Another statute covers Medicaid and Medicare fraud. It is illegal to knowingly and willfully execute or attempt to execute a scheme:
- To defraud any health care benefit program; or
- 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 care benefit program.
The penalties are up to ten years in federal prison for each count of misrepresentation. If the violation results in serious bodily injury, such person shall be imprisoned not more than 20 years. If the violation results in death, such person shall be imprisoned for any term of years or for life.
Medicare and Medicaid fraud are serious crimes that demand a large amount of investigation and understanding of healthcare billing rules. Attorney William Roelke of Roelke Law has over 20 years of experience studying the rules and ever changing requirements of Florida and federal healthcare compliance. As these cases demand time and resources, it is best to get started on your defense right away. Call (904) 354-0333 to discuss your case and learn more about the justice system and the process that may lie ahead. Our top priority is to dismiss the case and get you back to work. Bill Roelke is licensed in federal and Florida courts, and can assist clients in Duval County, St. Johns County, Clay County, Nassau County, and across Northeast Florida.