Government insurance programs help those who qualify for the coverage. Medicare assists people 65 years of age or older, and Medicaid helps persons with low incomes. As with other insurance programs, the insured may seek care from physicians and other health care providers who accept Medicare or Medicaid. Unfortunately, some providers may engage in fraudulent behavior.
Examples of Medicare and Medicaid fraud
Someone who attempts to procure Medicaid or Medicare funds through illicit means could be guilty of fraud. Billing these government entities for something that was never performed would be one typical example of fraud. Besides false or overbilling, someone could order unnecessary tests or even procedures. Monetary compensation may guide such unethical behavior.
When a patient receives a statement breaking down services performed and the related cost and billing information, it may be helpful to review the document for accuracy. Anything out of the ordinary may warrant an investigation.
Fraud vs. misunderstandings
Medicare and Medicaid fraud fall under the category of white-collar crimes. Like other criminal proceedings and investigations, suspects are presumed innocent until proven guilty. Sometimes, misunderstandings and mistakes could lead authorities to suspect fraud when none exists.
Perhaps a billing department made double-billing errors consistently, and no one in the accounting department caught the mistake. Investigators may assume fraud, although that is not the case. Perhaps the situation may resolve before the filing of charges. In some instances, a defendant may need to prove innocence in court.
Persons accused of white-collar crimes have constitutional rights, which authorities must attain evidence legally, among other requirements. Violations of constitutional rights could undermine a prosecutor’s case, leading to a potential dismissal.