Our health care system and government health care programs like Medicare are complex. In light of these complexities, it shouldn’t be a surprise that medical professionals are accused of abusing or defrauding Medicare from time to time.
Sometimes Medicare fraud and Medicare abuse are lumped together. It’s important to understand, however, that the two are different.
Fraud vs. abuse
The biggest key to determining whether someone committed fraud or abuse is the person’s intent. Medicare fraud occurs when someone knowingly attempts to receive inappropriate payments or abuse the system in some manner.
Common types of actions that may be considered Medicare fraud include:
- Knowingly submitting false claims
- Billing Medicare for an appointment that the patient didn’t keep
- Charging Medicare for more complex services than what the client received
Medicare abuse involves seeking improper payments from Medicare, too. The primary difference between the two is that Medicare abuse is seen to be accidental in nature.
Actions that may be considered Medicare abuse include:
- Misusing codes on a Medicare claim
- Excessively charging Medicare for medical procedures or supplies
- Billing Medicare for unnecessary procedures
Those convicted of Medicare abuse may be subject to criminal and civil liability. Penalties for Medicare fraud are more severe than the penalties for Medicare abuse. Convictions of Medicare fraud can result in fines, penalties and even prison time.
Being accused of Medicare fraud or abuse can be stressful. Understanding what is and isn’t considered Medicare fraud can help people feel more confident about their defense strategy.