If you have any experience in personal injury cases, chances are you groan with frustration at even the thought of handling a case involving a Medicare lien. If you start early, and remain organized, you can prevent Medicare from holding up your settlement check at the end of your case, which can happen if you do not have Medicare’s final demand when it’s time for the adjuster to issue the settlement check. Contact Medicare’s Benefits Coordination and Recovery Contractor (BCRC).The BCRC collects the information for Medicare and opens the file with the Medicare Secondary Payor Recovery Center (MSPRC). Submitting False Or Fraudulent ClaimsOne of the most common forms of healthcare fraud is the submission of false or fraudulent claims. These claims can take a variety of forms. This could include creating a claim for services that were never performed at all or were performed by someone else. Not all claims of fraud involve falsified care. In many cases, healthcare providers profit from performing tests or treatments that are unnecessary. This can also include what is known as “upcoding.” Upcoding involves billing Medicare or Medicaid with the most expensive medical devices or treatments available but providing them with less expensive options. The doctor would then pocket the difference. Making Duplicate ClaimsDouble billing is another common form of fraud. This type of fraud is often more deceptive than simply submitting the same claim documentation twice. Often, medical providers will order a battery of tests and submit them all as a single claim. If the provider then submits an additional claim for a single test out of that battery with the intent to defraud Medicaid or Medicare, they could face federal charges. Manipulating Undercharging RequestsMany providers use the high volume of claims from their office as cover for fraudulent activity. Because of the complexity of billing, it is common for over or under-billing to occur. Typically, providers will submit a bill when they discover they undercharged. Conversely, the providers are required to return payments when they discover they have overcharged for their services. A common form of fraud involves requesting payment for undercharges but failing to report any overcharges. Using KickbacksThe Anti-Kickback Statute prevents acts of self-referral. This form of fraud does not directly involve filing a claim with Medicare or Medicaid. Instead, the fraud occurs by referring a potential patient to a care provider that you have a financial interest in. This could include a family member’s medical practice or another provider that you have a kickback agreement with. Proving Medicare Of Medicaid Fraud In UtahThe specific elements of a healthcare fraud case depend on the type of fraud that is alleged. In each case, the federal prosecutor must establish that you have committed that specific type of fraud, whether it is filing fabricate claims or seeking double payment. There are two important elements that the government must meet in each case: knowledge and intent. The absence of these elements can be fatal to the government’s case. First, to be guilty of fraud you must know that the claims you are submitting are fraudulent or otherwise unlawful. This can result from falsifying medical records yourself or knowing someone else has done so. This provision protects someone who has made an honest mistake from prosecution. This mistake could have occurred in the claims process or within the medical records. In addition to knowledge, the government must also show you had the intent to defraud these federal programs. This concept is similar to having knowledge of fraudulent documentation, but there is an important difference. There are other reasons besides fraud that a person could be motivated to alter records. If a person alters medical records to avoid being fired for breaching a company policy, they may not be guilty of healthcare fraud. Unfortunately for them, there are other criminal statutes that likely apply. Possible Penalties Of Federal Medicare Or Medicaid FraudThere are multiple federal statutes that provide potential criminal liability for healthcare fraud. These penalties differ depending on the specific allegations. The two statutes most commonly used in Medicare and Medicaid fraud prosecutions include: Collateral ConsequencesWhen it comes to accusations of Medicare or Medicaid fraud, it is understandable if a potential prison sentence dominates your thoughts. It is important to understand that there can also be collateral consequences for a conviction. These consequences typically center around professional licenses. Doctors, surgeons, and nurses all require a license to practice their chosen profession. The governing bodies that govern these licenses are typically state agencies, and they have a keen interest in allegations of fraud. If you are convicted or plead guilty to a fraud charge, the odds of you losing your medical or nursing license forever are strong. This aspect of fraud charges is one strong reason why plea bargains are not always in your best interest. While the courts and prosecutors can promise that you will avoid prison or face limited penalties with a guilty plea, they have no power over state regulatory bodies. Your best chance to keep your medical license is to beat the charges against you. Common Defenses Of Medicare & Medicaid Fraud In UtahThere is no guarantee that an accusation of healthcare fraud will result in your conviction. Your attorney could play a major role in this determination by crafting an appropriate defense. The best defense in your case will depend on the facts involved. For some, actively proving an affirmative defense makes sense. In other cases, relying on the federal government’s lack of evidence is enough. Some of the common defenses for Medicare or Medicaid fraud charges include: Personalized plan structuresMedicare Advantage offers different plan types for your personal situation. For example, if you have a chronic health condition, an SNP Advantage plan can help with your medical costs. If you prefer provider freedom, a PPO or PFFS plan may be more of what you’re looking for. Cost-saving opportunitiesResearch Trusted Source has shown that you can save money on laboratory services and medical equipment by switching to a Medicare Advantage plan. In addition, some Advantage plans have no costs for certain premiums or deductibles. Another advantage of choosing Medicare Advantage is that there’s a yearly maximum out-of-pocket amount. Coordinated medical careMany Medicare Advantage plans are offered under structures that take advantage of coordinated medical care. This means that any providers you visit will be in communication with each other to provide you with coordinated, effective medical care. Limited service providersIf you choose one of the more popular Medicare Advantage plan types, such as an HMO plan, you may be limited in the providers you can see. You may even face higher fees if you choose to an out-of-network provider with these plans. Other plan types do give you more provider freedom, though those plans may be limited and costly. Medicare Defense Lawyer In UtahWhen you need legal help for medicare defense, please call Ascent Law LLC for your free consultation (801) 676-5506. We want to help you.
Ascent Law LLC
8833 S. Redwood Road, Suite C West Jordan, Utah 84088 United States Telephone: (801) 676-5506
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