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How the federal government diagnoses Medicare fraud

As a medical professional -- physician, nurse or pharmacist -- there was perhaps no more satisfying moment than when you walked across the graduation stage to receive your diploma, the personification of all your academic achievements.

However gratifying as this moment was, it really represented only the first step on an otherwise demanding career path that has necessitated the acquisition of professional licensure, the establishment of a strong professional reputation among peers, and, of course, the building of trusting relationships with patients.

Given all of this hard work, dedication and sacrifice spent advancing their careers, it can understandably prove to be truly shocking for medical professionals to learn that they are under investigation or being charged by federal officials for having committed some manner of health care-related fraud or abuse.

Indeed, the federal government has long devoted considerable money and resources to combat fraud and abuse concerning Medicaid, the program that provides financial assistance with medical costs to those with limited incomes and/or resources.

Fraud

According to the U.S. Department of Health and Human Services, Medicaid fraud occurs when a medical professional makes an intentional deception or misrepresentation with the full knowledge that it could result in the realization of an otherwise unauthorized benefit to themselves or a third party.

Abuse    

Similarly, the HHS indicates that Medicaid abuse occurs when a medical professional's conduct runs contrary to established medical, business or fiscal practices, and results in 1) reimbursement for medically unnecessary services, 2) reimbursement for services that fail to meet accepted medical standards, or 3) unnecessary costs to the Medicaid program.

The purpose in sharing this information is not to cause medical professionals to experience unnecessary alarm, but rather to empower them with the necessary knowledge.

We'll continue this discussion in our next post, exploring more about the specific types of Medicare fraud, and the potential penalties of a conviction.

If you are a licensed medical professional who is under investigation by state or federal officials for some manner of health care fraud, consider speaking with a skilled legal professional to learn more about your options for protecting your freedom, your reputation and your livelihood. 

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Darryl A. Goldberg
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