How the federal government diagnoses Medicare fraud – II

On Behalf of | Feb 1, 2017 | Federal Crimes |

Last week, we discussed just how shocking it can be for medical professionals, who have spent so much time pursuing their education, advancing their careers and building a reputation, to discover that they are under investigation or facing federal charges for some manner of Medicaid fraud or abuse.

Specifically, we spent some time exploring how the U.S. Department of Health and Human Services defines these two broad and incredibly important terms. In today’s post, we’ll continue delving deeper into this issue, examining the types of conduct that fall under either heading.      

As was the case last week, our purpose in sharing this information is not to cause medical professionals unnecessary alarm, but rather to empower them with the necessary knowledge so that they can avoid inadvertently running afoul of the law.


While lacking a precise definition in the Social Security Act or associated federal regulations, upcoding is essentially the illegal practice of billing for more complex services than were actually provided.

By way of example, consider a physician who sees patients for simple office visits, yet bills for more complex visits, or a medical supplier who bills for motorized scooters, yet provides standard manually operated wheelchairs.

Billing – Services or Items not provided

Medical professionals are expected to bill only for those services, supplies and/or items that are actually provided to patients, and ensure that the proper paperwork documenting the provision of these services is in place.

Trouble can arise when Medicaid is billed for services that were never provided, and supplemented by either a false or otherwise nonexistent paper trail. By way of example, consider a physician signing charts and submitting bills for tests that were never run.

Billing – Unnecessary items or services

The Social Security Act leaves it to the 50 states to safeguard against the unnecessary utilization of Medicare services and, to that end, vests them with the authority to define what qualifies as a medically necessary service.

What this essentially means is that medical professionals, no matter their location, may not intentionally bill for unnecessary services, supplies or items, and must ensure that the services, supplies or items they provide fit the criteria for medical necessity in their state.

We’ll conclude this discussion in a future post, exploring several more types of Medicare fraud and the potential penalties called for under the law.  

Consider speaking with a skilled legal professional if you are a licensed medical professional who is under investigation for some form of health care fraud, as your freedom, your reputation and your livelihood may be in jeopardy.


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