What to expect if you face Medicare fraud allegations

On Behalf of | Mar 8, 2021 | Criminal Defense

As a medical provider who participates in Missouri’s Medicaid program, you must follow a vast number of rules and regulations. The sheer number of requirements can leave you confused and unable to keep up with the mandatory requirements. This can result in you becoming subject to an investigation by the Missouri Medicaid Audit & Compliance Unit.

According to the Missouri Department of Social Services, the MMAC looks into fraud, abuse and waste allegations by providers and participants.

Medicare Fraud

Medicare and other Federal health care programs rely on your judgment as a medical provider when treating patients. The programs trust that you provide the items and services they need. Medicare fraud includes knowingly submitting false claims, making misrepresentations of fact to receive a Federal health care payment and making prohibited referrals for certain health care services. It can also include knowingly receiving, soliciting, paying or offering kickbacks, rebates or bribes that induce Federal health care program referrals.

Fraud allegations

If the investigation uncovers reliable allegations of fraud, the MMAC turns the information over to the Medicaid Fraud Control Unit. When this occurs, you will receive a letter notifying you of a fraud investigation. A team digs into your organization looking for a broad range of issues that may include the following:

  • Claims for falsified patient
  • Upcoding, unbundling and double billing
  • Illegal fee sharing
  • Billing for services not received

The investigating team may request documents dating back months or years. Understanding federal laws is critical for preventing disastrous consequences. Depending on the situation, you could not only lose customers and have significant fines levied, but you may face the loss or suspension of your license and criminal charges.