Medicare and Medicaid Fraud

Medicare Prosecutions and Fraud charges are a hot topic today. Today our Federal and State authorities prosecute many people for Medicare and Medicaid Fraud. This fraud prosecution usually stems from people who overcharge Medicare or Medicaid for services they render. The services can be for any medical services provided to patients such as ambulance transportation or doctor treatments. Usually these prosecutions pose the potential for imprisonment for professional clients who have never seen the inside of a jail. There is a better way…

Fines and restitution. While Health care fraud cases usually result in jail sentences, especially if they are prosecuted federally, why can’t we seek to impose more fines and restitution and less jail? If a professional has been investigated for ripping off Medicare and Medicaid, why put the person in jail? If there is money taken from they system then a civil remedy can be sought.

While I see many Wall Street brokers who commit securities fraud end up only paying fines it is not the same in the health care context. I suggest a more rigid application process to be put in place so less qualified people won’t become Medicare/Medicaid providers in the first place.

Next increase education to the providers, many don’t know they are committing what is known under the law as fraud. The law behind this fraud is very complicated. I will share some of it at the end of this piece. Have the providers get ten to fifteen hours a year of continuing education so they can better understand the regulatory framework they are involved in.

Instead of arresting right away the regulators should provide more consistent audits which along with education help the provider do the right thing. I was involved in a case many years ago where there was no medical oversight over my client who really didn’t understand the consequences of her actions. Everyone in the medical community has to “step up their game” and realize that fraud costs our society billions of dollars and more education is the key not incarceration.

If a person goes to jail there can be no monies paid back to the system and restitution will be impossible. The system will then just go back and tax the consumers (society) for the losses. More education and training can help folks get back on track and contribute to the medical systems we all rely on.

Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS), an agency of the United States Department of Health and Human Services. Medicare pays for the reasonable and necessary medical services for people aged 65 and older and some persons under 65 with certain illness and/or disabilities. Medicare is a “health care benefit program” as defined by Title 18, United States Code, Section 24(b).

Medicaid is a system of medical assistance for indigent individuals who are aged, blind, disabled, or members of families with dependent children. The program is funded by both the federal and state governments. Pennsylvania Medicaid, also known as Medical Assistance, was governed by the Commonwealth of Pennsylvania Department of Public Welfare. Medicaid is a “health care benefit program” as defined by Title 18, United States Code, Section 24(b). See the following for the law on this.

https://www.govinfo.gov/content/pkg/USCODE-2009-title18/html/USCODE-2009-title18.htm

For more info on CMS see the below link.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf