Medicare & Medicaid Frauds

Medicare & Medicaid Frauds

The federal Medicare and Medicaid programs were created in 1965 by Titles 18 and 19 of the Social Security Act. 42 U.S.C. §1395 et seq. The programs were designed to “provide a hospital insurance program for the aged under the Social Security Act with a benefits program and an expanded program of medical assistance to increase benefits under the Old-Age, Survivors, and Disability Insurance System, to improve the Federal-State public assistance programs, and for other purposes.”

  • Medicare is a health financing program for the elderly that is backed by federal dollars. The government contracts with insurance companies and intermediaries to pay out on claims for reimbursement that are filed by health care providers or the Medicare beneficiary. The payees of claims are then reimbursed by the government.
  • Medicaid is a health financing program specifically for low-income individuals. Each state administers their own Medicaid program and receives reimbursement from the federal government for a percent of the program’s costs.

Due to the complexity of the Medicare and Medicaid programs, they are ripe for fraud schemes. In fact, health care fraud costs the U.S. billions each year. The very nature of these programs involves multiple organizations, state and federal laws and governmental bodies, contractors, and a complicated web to ensure patients get the health care they need and providers are paid for giving that care.

Further, the reimbursement principles under these programs has grown increasingly complicated. Some health care providers are paid directly by the program and some are paid by the patient, who is the reimbursed by Medicare. Different entities are paid under different methodologies like cost-based, charge-based, or fee schedules, and may be subject to pay-out limits of the health care plan.

Medicare & Medicaid Frauds

Medicare and Medicaid fraud schemes fall under the purview of health care fraud and are white collar crimes. Health care fraud is committed when a person or organization defrauds the health care system in order to obtain funds or services. These fraud schemes can be carried out in a number of ways, and may involved complex, large-scale, and far-reaching schemes. Common Medicare and Medicaid fraud schemes involve fraudulent billing, such as billing for medical services that were never performed or were not medically necessary, billing for phantom patients, and upcoding, which is billing for pricier procedures than were actually performed.

Fraud schemes against Medicare and Medicaid can be prosecuted under a number of criminal statutes. Beneficiaries and providers can be prosecuted under federal law for making material false statements, submitting false claims, or being a party to a kickback scheme. And criminal charges for health care fraud are prosecuted aggressively. The federal government expends an enormous amount of resources to investigate and prosecute health care fraud cases. In these types of cases prosecutors go after dramatic punishments.

If you are under investigation for or have been accused of defrauding Medicare or Medicaid, you need an attorney experienced in complex health care fraud cases who can combat aggressive prosecutors.

Hire A Former Health Care Fraud Prosecutor To Defend You

Health care fraud is a highly complex area of law requiring specialized knowledge. As a former health care fraud prosecutor with the United States Attorney’s Office, Ashley D. Adams has the requisite knowledge and understands the tactics and procedures the government will use to obtain a conviction. She understands how prosecutors operate, and the best tactics to use to mount a strong defense against health care fraud allegations. Given her prior work, she also has a longstanding and positive relationship with the U.S. Attorney’s Office, the Attorney General’s Office, and the Department of Justice. Put Ashley D. Adam’s experience to work for you.

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


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