What is Medicare Fraud?


According to the law (ORC 2913.40), Medicare fraud is said to have happened if a Medicare provider intentionally/knowingly/deliberately makes a misleading statement or misrepresents material facts used to obtain compensation from the government medical assistance program.

Medicare Offenses

Medicare fraud includes:

  • Phantom billing – Billing for treatments/services not provided
  • Up-coding – Charging above the reasonable value of services rendered
  • Providing services which are unnecessary
  • Unbundling – billing separately for services which are typically charged together
  • Double-billing – billing for the same service twice
  • Billing brand-name drugs while dispensing generics
  • Bribery
  • Kick-backing – accepting or giving something in return for medical services
  • Embezzling recipient funds
  • Giving false cost reports

Medicaid providers include dentists, doctors, nursing homes, counselors, hospitals, pharmacies, clinics, at-home caregivers and any other parties that can be paid by the Medicaid program.

Medicaid and Medicare Fraud and Abuse

Types of Medicare Fraud and Abuse

A Medicare fraud is said to have happened when an individual or organization obtains Medicare reimbursement when they are not legally entitled to do so. Like Medicaid fraud, this covers a vast group of offenses, but all lead to this one end: illegally collecting reimbursement from the Medicare program.


Given that not all Medicare fraud is detected and/or reported, it is difficult to state the exact sum of funds that are lost through fraud. This program is ripe for fraud given that it follows an honor billing system, and has likely lost over 10 billion annually to fraud. Just like Medicaid fraud, Medicare fraud typically occurs in three main ways.

  • Phantom billing
  • Patient billing
  • Up-coding

Medicare Fraud Cases

The integrity of Health and Human Services programs, of which Medicare/Medicaid are a part, is protected by the Office of the Inspector General in charge of the US Department of HHS. Their investigatory office in collaboration with the FBI follows up on all cases reported to root out Medicare/Medicaid fraud.

From January 2009 to June 2012, the Justice Department was successful in recovering more than $7 billion paid to fraudulent claims, including a massive $8.9 million that was paid to a single New Jersey Hospital, Overlook Hospital. The hospital had over-billed Medicare by treating patients who qualified to be treated as outpatients on an in-patient basis.

What is Medicare Fraud and Abuse

Medicare Fraud Penalties

Medicare fraud in NY is still prosecuted as a Federal crime, and attracts very harsh penalties depending on the value of the fraud. Healthcare providers who are convicted are looking at major consequences including restitution, heavy fines, significant jail time, deportation of non-citizens and loss of practicing rights.

Typically, every offense can carry an individual sentence of up to five years. This means that if a person is found guilty of committing five different fraudulent transactions, they could be facing up to 25 years imprisonment.

Medicare Fraud Defense Lawyer

Clearly, Medicare fraud charges are no small matter. If you are arrested, accused of being investigated and/or charged with Medicare/Medicaid fraud, contact the Law Office of Stephan Jacob Siegel, Esq. in NY to schedule your free initial consultation and case evaluation.