As the health care industry becomes more complex, so does compliance regarding the False Claims Act, Medicare Fraud, Medicare Abuse, Anti-Kickback Statute (AKS), Stark Law, and Criminal Health Care Fraud Statute.
Below is a brief summary as to how medicare fraud may be defined and/or interpreted.
Medicare fraud typically includes any of the following:
- Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist;
- Knowingly soliciting, receiving, offering, or paying remuneration (e.g., kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by Federal health care programs; and/or
- Making prohibited referrals for certain designated health services.
Anyone can commit health care fraud. Fraud schemes range from solo ventures to widespread activities by an institution or group. Examples of Medicare fraud include:
- Knowingly billing for services at a level of complexity higher than services actually provided or documented in the medical records;
- Knowingly billing for services not furnished, supplies not provided, or both, including falsifying records to show delivery of such items;
- Knowingly ordering medically unnecessary items or services for patients;
- Paying for referrals of Federal health care program beneficiaries; and/or
- Billing Medicare for appointments patients fail to keep.
Courtesy of CMS (2/19)
