Recently, five Philadelphia nurses were charged with involvement in a $9 million Medicaid fraud scheme. The Pennsylvania attorney general's office has taken a strong stance against perceived instances of fraud in the state's Medicaid program. According to statistics cited by the attorney general's office, approximately 10% of the costs of health care are the result of fraud. Under Pennsylvania law, any instance of Medicaid fraud can be charged as a third degree felony, with a potential prison term of seven years and a fine of $15,000.
The Pennsylvania Attorney General's office has identified the most common types of Medicaid fraud, which include:
- Billing for services not provided-This entails billing Medicaid for services not rendered, and can include medical, dental or other covered care.
- Misrepresentation of services rendered-This typically involves allegations of billing for services other than those actually provided.
- Kickbacks-A service provider cannot be paid a fee for referring patients to another provider.
- Unbundled supplies-This involves taking services that are normally provided together and billing Medicaid separately so as to get larger payments.
- Drug diversions-This involves prescribing drugs when there is no medical necessity.
- Providing substandard care or services that are not medically necessary-This may involve using unlicensed personnel; billing for services actually rendered, but not needed; or for providing care after a patient is fully recovered.
Unlike many crimes, most insurance fraud cases are prosecuted by special units within police departments and prosecutors' offices. Although these prosecutions require a considerable amount of investigation, law enforcement now has the necessary manpower, resources, and technology because these crimes have been made a priority by top prosecutors.
If you suspect that you or someone you know are a target of a Medicaid fraud investigation, you should immediately contact a lawyer who has experience with fraud investigations and criminal defense. Tim Tarpey is a criminal defense attorney, former prosecutor, and Certified Fraud Examiner (CFE) with experience defending charges of white collar crime. Our Philadelphia white collar crime attorneys have more than 40 years of combined experience. Talk to an experienced attorney before you speak to an insurance company or law enforcement officer. Call us at (215) 352-3432.