Physicians who bill Medicare have a duty to be honest and forthright in how they conduct themselves. There are a variety of laws regarding Medicare fraud and abuse, and the penalties for breaking them are stiff.
Fraud and abuse differ in certain ways, but they both result in unnecessary costs. Even if a doctor has good intentions, some of their actions may result in abuse.
Fraud vs abuse
The Centers for Medicare and Medicaid Services defines the differences between fraud and abuse. Physicians commit fraud when they knowingly submit false claims, receive or give kickbacks for services or refer to prohibited individuals or organizations.
Medicare abuse refers to practices that do not meet standards of care or provide unnecessary services. Those that commit abuse are more likely to bend the rules as opposed to deceive the government intentionally.
The Federal laws that govern physicians include:
- Anti-Kickback Statute
- False Claims Act
- Physician Self-Referral Law
- United States Criminal Code
- Civil Monetary Penalties Law
- Exclusion Statute
Any fraud or abuse relating to these laws is subject to criminal and civil penalties.
Examples of Medicare abuse
The U.S. Department of Health and Human Services discusses that one does not need to have the intent to defraud to commit abuse. Simple recklessness or ignorance constitute abuse, and some examples include charging excessively for supplies, billing for services that are unnecessary and unbundling or upcoding billing codes.
Potential consequences if convicted
Committing abuse can result in civil and criminal liabilities. Potential penalties include imprisonment, fines or both. Because there are penalties for each violation, the number of fines can increase quickly.