Laws To Curb Medicaid Fraud

Medicaid fraud is the illegal and alleged misrepresentation of facts and figures to get access to the various types of benefits available under the Federal Medicaid Scheme. This fraud has started to spread vigorously across various regions. The individuals involved in this type of fraud commit the offence in a more planned and in an organized manner.

It is an undeniable fact that most of the healthcare providers are striving hard to deliver quality services with high standards and also keep up their dignity and submit and record only correct bills and information’s in a very legitimate manner. However there are a few who commit Medicaid fraud as an organized crime and pose a severe threat to these healthcare programs.

Governing Laws:

In order to curb the fast spreading Medicaid frauds there are a number of federal and state enforced laws to curb this malpractice and punish the lawbreakers. Some of the most important aspects covered under the federal law consist of:

  • 6127243966_0de6283cd8_o-1024x768The Health Care Fraud Statute:

Under this it is a criminal offence to allegedly execute a plan to misrepresent and swindle benefits from a healthcare benefit program. Individuals found guilty under this section is subject to punishment by imprisonment for up to 10 years and might also include a criminal fine amounting to $2,50,000. Any specific intent is not required to violate this section is not required.

  • False Claims Act:

This act creates a civil liability for such offences that might relate to knowingly and willfully presenting false claims in order to receive the benefits under the plan. The offence also includes any act done to conceal the actual records and making false records to substantiate the claims. Some of the frauds covered under the False Claim Act include:

  1. Upcoding
  2. Billing for unnecessary services
  3. Billing for services not rendered
  4. Billing for services provided by disqualified individuals.

People found guilty under this act are punishable with imprisonment of up to 5 years and a criminal fine up to $ 2,50, 000. This might also lead to the exclusion of the service provider from the federal health care programs. Adding to this the guilty person would also be subjected to civil legal actions for penalties and the government, any private party, competitors or even an employee of the service provider company may file damages under the act.

  • Anti Kick Back Statute:

Kick back refers to knowingly and willingly offering or accepting remuneration for illegal favors. To curb this malpractice, the Anti Kick back Statute was formulated under the Social Security Act. Find more about Medical Fraud on this link The remuneration might be of any type that includes products, services or any monetary benefits. Compliance with Anti Kick Back Statute is an underlying requirement for payments from Federal Health care programs. Violations if any found regards to the compliance, would result in fraud under the False Claims Act.

Individuals found guilty under the Anti Kick back Statute would be subjected to an imprisonment of up to 5 years and a criminal fine of $2,50,000.

  • The Patients Access and Medicare Protection Act:

This act was formulated to impose stricter and stringent penalties to individuals who illegally and willfully involve in activities such as buying, selling or distributing Medicaid data’s, numbers and other crucial data. More than any other frauds under any other sections, frauds committed under this section would attract severe legal punishment that would include a imprisonment of up to 10 years and a criminal fine of up to $5,00,000.

  • Exclusions Provision:

This exclusion provision of the Social Security Act authorizes the HHS-OIG to exclude individuals from taking part in Federal healthcare Programs. Exclusions might be mandatory or discretionary.

Medicaid Costs

Mandatory exclusions might arise due to the following offences committed by the individual or the health care providing company:

  1. Health Care Program related crimes
  2. Convictions related to abuse of patients.
  3. Crime Convictions
  4. Convictions related to health care fraud
  5. Criminal conviction related to controlled elements.

Reasons for Discretionary exclusions include:

  1. Loss of License
  2. Conviction related to fraud.
  3. Violation convictions related to controlled substances
  4. Conviction related to impediment of an investigation
  5. Willful participation in prohibited acts such as kickbacks.
  • Civil Monetary Penalties law:

This law authorizes the HHS-OIG to impose civil penalties for violations of any the acts and laws covered under the sections of law formulated to curd Medicaid frauds in any form. The Penalties under this act range from $10,000 to $50,000 depending upon the number of violations.