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Medicare and Medicaid Fraud

Medicare/Medicaid fraud is the act of intentionally providing false medical coverage information to obtain medical benefits. Medicare/Medicaid fraud can be committed by patients, healthcare facilities, or parties pretending to be healthcare providers.

There are various types of Medicare and Medicaid fraud a person can commit. Some examples include billing for services that were not provided, performing unnecessary tests, abusing patients, filing claims for reimbursement to which the applicant is not legitimately entitled, and committing identity theft to receive services.

If an individual is charged with Medicare or Medicaid fraud in Texas, they could be facing some serious life-changing penalties. The penalty for Medicare/Medicaid fraud ranges from a Class C misdemeanor to a felony of the first degree, dependent on several factors.

If you have been charged with Medicare or Medicaid fraud, we suggest you contact an attorney as soon as possible.

Attorney for Medicare and Medicaid Fraud in San Antonio, Texas

Healthcare fraud has cost the nation billions of dollars each year, which has resulted in higher health insurance premiums. Fraudulent practices not only increase Medicare and Medicaid costs but increase the chance of potential harm to patients who are subject to unnecessary procedures.

If you have been charged with Medicare or Medicaid fraud, you must contact an attorney at Goldstein & Orr. Our attorneys will provide you with exceptional legal services to help fight your case. We will answer all your questions and enlighten you with all the legal procedures for your case. Goldstein & Orr serves clients throughout the Country. Make sure to call (210) 226-1463 to speak with the attorneys at Goldstein & Orr.

Overview Medicare/Medicaid Fraud:

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What is Medicare/Medicaid Fraud

Under Texas and Federal law, Medicare and Medicaid fraud are classified as a white-collar crime. Health Care Fraud is defined as having the intent to deceive health services in an effort to obtain a personal benefit. There are also external auditors whose responsibility is to assess suspicious claim patterns.

To help prevent Medicare/Medicaid fraud relating to identity theft, Medicare employed a new program in 2018. The latest program issued participants with new ID cards that include a Medicare number instead of a social security number. Preventing fraud is a priority for departments that oversee these programs.


But there are flaws in Medicare and Medicaid regulation and monitoring.  And flaws in the requirements for billing for medical services.  Goldstein & Orr lawyers know what these flaws are and of defenses to fraud allegations. Contacting Goldstein & Orr once you are aware that any inquiry is being made in relation to Medicare/Medicaid will put you in the best position to know how to respond and to learn what it is best to do.

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Types of Medicare/Medicaid Fraud

There are various ways an individual or medical provider can commit fraud. Below are a couple of common examples of Medicare/Medicaid fraud committed in the U.S.

  • Intentionally billing for services that are not needed or provided. A common example is a doctor billing for procedures that were never performed, also called phantom billing.
  • Sharing Medicare/Medicaid information with another individual so they can obtain medical services, also known as card sharing.
  • Claiming reimbursement for someone other than the eligible beneficiary.
  • Altering prescriptions to obtain drugs for personal use or to sell.
  • Committing identity theft to obtain medical services by pretending to be an individual who is eligible to receive services.
  • A healthcare clinic billing a patient for services already paid for by Medicare/Medicaid.
  • A healthcare organization billing Medicare/Medicaid for the care given to patients who have passed away or no longer eligible.

As you can see, these are just a couple of many types of Medicare/Medicaid frauds committed. An individual or healthcare provider that is accused of Medicare/Medicaid fraud will be subjected to criminal or civil investigation.

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Medicare/Medicaid Fraud Penalties

In the state of Texas, the punishment for a Medicare/Medicaid fraud conviction can be severe. Penalties can range from Class C misdemeanor to a felony of the first degree. Medical workers who have been convicted of fraud can also lose their healthcare license. Furthermore, a healthcare business convicted of Medicare/Medicaid may be deemed ineligible for healthcare services in the future.

Below are the punishments of Medicare/Medicaid fraud in Texas:

  • A Class C misdemeanor if the amount of any monetary claim is less than $100.
  • A Class B misdemeanor if the amount of any monetary claim is more than $100 but less than $750.
  • A Class A misdemeanor if the amount of any monetary claim is more than $750 but less than $2,500.
  • A state felony if the amount of any monetary claim is more than $2,500 but less than $30,000.
  • A felony of the third degree if the amount of any monetary claim is more than $30,000 but less than $150,000.
  • A felony of the second degree if the amount of any monetary claim is more than $150,000 but less than $300,000.
  • A felony of the first degree if the amount of any monetary claim is more than $300,000.

Below are the federal health care fraud statutes for Medicare/Medicaid fraud:

  • False Claims Act (18 U.S.C. § 287) – A healthcare provider cannot deliberately submit false or fraudulent claims to the federal government under Medicare/Medicaid programs. A felony conviction can carry up to five years imprisonment and a fine of $250,000 for an individual and $500,000 for a corporation. A misdemeanor conviction could result in a fine of up to $100,000 for an individual and $200,000 for a corporation.
  • False Statements Act (18 U.S.C. §1001) – It’s illegal for a healthcare provider to make false or fraudulent statements to the federal government that would shape the judgment on whether reimbursement for services should be provided. A conviction for making a fraudulent statement is imprisonment for up to five years and a $100,000 fine. For every false statement made, a new charge can be added. As charges increase, the defendant can face many years of prison time and larger fines.
  • Health Care Fraud (18 U.S. Code § 1347) – It is illegal to knowingly perform a plan to defraud any health care benefit program or obtain any money or property owned from any health care program utilizing fraudulent claims. The penalties are up to ten years imprisonment. If the violations result in serious bodily injury, the individual can be imprisoned for no more than 20 years. If death is a result of the violations, the individual could be imprisoned for life.

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Additional Resources

Texas Medical Fraud Laws – Visit the official website for the Texas Constitution and Statutes for more information on medical fraud. Learn about the various ways one can commit fraud in the healthcare industry.

Types of Medical Frauds – Visit the official site for medical services to find information regarding the various types of medical frauds. Learn about the different types of medical fraud, with examples given for each one.

Medicare/Medicaid Statistics in Texas – Visit the official Medicaid site to find information regarding Medicaid in the country. Learn about each state’s policies and statistics concerning medical coverage.

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Lawyer for Medicare or Medicaid Fraud in San Antonio, Texas

If you have been charged with Medicare or Medicaid fraud, you must contact the proper attorney for your case. Medicare/Medicaid fraud can lead to severe consequences if not handled properly. You can receive hefty fines or a lengthy punishment.

Our defense team at Goldstein & Orr has years of experience with medical fraud crimes in Texas. We will establish a terrific defense team that will fight for your rights. We accept clients throughout the greater San Antonio metropolitan area and Bexar County. Give us a call for a free consultation at (210) 226-1463.

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