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What are Medicare fraud and Medicare abuse?

Medicare fraud and Medicare abuse are crimes that the federal government takes very seriously. This is due in part to the effect that this type of behavior has on the health and wellbeing of Medicare recipients, but also because of the financial impact that it has on the Medicare Trust Fund. There are several points regarding Medicare fraud and abuse that providers must be aware of when they are treating Medicare patients because even unintentional violations can lead to criminal charges.

What is Medicare fraud?

Medicare fraud occurs when a provider bills Medicare for services that weren't rendered to the patient. This can also include seeking payments through false statements or misrepresentations in an effort to get a payment that doesn't meet the qualifications for an entitlement. Billing for a higher-level procedure than the one performed is another example of Medicare fraud.

Who can commit Medicare fraud?

Medicare fraud isn't limited only to doctors. Instead, anyone who knowingly tries to bilk the government for money based on phony Medicare claims can be charged with Medicare fraud. This can include organizations who are supposed to provide equipment or services to Medicare patients but fail to provide the items or service claimed in the payment requests.

What is Medicare abuse?

Medicare abuse is one step under Medicare fraud. Medicare abuse is akin to bending the rules instead of intentionally deceiving the program. Misusing codes, charging excessive amounts and billing the program for services that weren't necessary are examples of Medicare abuse.

There are several laws that apply to Medicaid abuse and fraud, including the United States Criminal Code, Social Security Act, Anti-Kickback Statute, False Claims Act and Physician Self-Referral Law. If you are being charged with Medicare fraud or abuse, you should understand how these laws apply to your case and learn your options for defense so you can fight against the charges.

Source: U.S. Department of Health and Human Services, "Medicare Fraud & Abuse," accessed Oct. 27, 2015

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