Avoiding Medicare Fraud: A Roadmap for Doctors

Avoiding Medicare Fraud: A Roadmap for Doctors

Medicare fraud is a white collar crime, and it is the most common form of health care fraud that is prosecuted. Health care fraud costs our country tens of billions of dollars every year, so prosecutors aggressively pursue instances of alleged fraud.

The coding system used for billing Medicare is complex. The proper procedures for reimbursement can be difficult to navigate. Innocent coding errors can happen. The fact is that even incidental billing errors or negligence can be identified as potential fraud. This is why it is critical for doctors to be proactive about billing best practices and avoiding activity that could raise a red flag.

Avoiding Medicare Fraud

Violating Medicare rules and regulations may result in criminal and civil liability, non-payment of claims, and exclusion from the Medicare program and all Federal health care programs.

It is necessary for doctors to comply with the U.S. criminal code, respective state laws, and specifically the False Claims Act, Anti-Kickback Statute, Social Security Act, and the Physician Self-Referral Law.

Fraud concerns may arise in a physician’s business relationships with:

  • Claim payers.
  • Vendors
  • Fellow doctors.
  • Other health care providers.

The following are a few areas where issues may arise:

  • Coding and billing.
  • Physician documentation.
  • Patient recruitment.
  • Prescribing practices.
  • Relationships with pharmaceutical or medical device companies.
  • Investments in health care business ventures.

Being diligent in the above areas is critical to avoiding allegations of Medicare fraud.

Medicare is a large program that involves multiple organizations, state and federal laws and governmental bodies, contractors, and complicated reimbursement principles. Understand that when you submit a claim for medical services for a Medicare patient, you are seeking reimbursement from the Federal government – the submission itself certifies that you earned the payment and  are complying with billing regulations. Inaccurate billing can be prosecuted.

Hire A Former Health Care Fraud Prosecutor To Defend You

If you have been accused of Medicare fraud you need a health care fraud defense attorney who understands the tactics and procedures the government will use to obtain a conviction. As a former health care fraud prosecutor with the United States Attorney’s Office, Ashley D. Adams understands these tactics and knows how to establish the best possible defense for your case.

Allegations of health care fraud can cause significant damage to your personal and professional reputation. Conviction of Medicare fraud, Medicaid fraud, or other health care fraud can result in harsh penalties, fines, even imprisonment. We have the experience and the resources to protect your rights and defend you against aggressive prosecution.

Contact us or call now (480) 219-1366 for a consultation.


The attorneys at Ashley D. Adams, PLC handle federal criminal cases throughout the United States, including Arizona, Oklahoma, Utah, and California.