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.
Obtain Medicare Information from the Client at the Initial Meeting and Warn Them that Medicare Liens are Difficult and Can Cause Delays throughout Their Case. In addition to finding out information about any type of lien claim at your first meeting with the client, be sure to find out if the client receives Medicare benefits. If so, make a copy of their Medicare card, and be sure to copy both sides. Ask the client if they have received any correspondence from Medicare; be sure to make copies of those as well. These may be in the form of Explanation of Benefits statements, bills, or letters. Most importantly, set your client’s expectations. As you will see, Medicare does not move quickly in providing information at any step of this process. Warning your client at the outset will prevent many anxious calls from your client at the end of your case when they are wondering why they have not gotten their settlement money.
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).
The information that you need to provide is as follows:
• Beneficiary Information: Name, Health Insurance Claim Number (HICN), Gender and Date of Birth, Address and Phone number
• Case Information: Date of injury/accident, date of first exposure, ingestion or, implant, Description of alleged injury or illness or harm, Type of Claim (Liability insurance, No-Fault insurance, Workers’ Compensation), Insurer/Workers’ Compensation name and Address
• Representative Information: Representative/attorney name, Law Firm name if the representative is an attorney, Address and Phone number
While Medicare and Medicaid are distinct programs with different recipients, the manner in which fraud affects them is the same. Healthcare fraud can come in many different forms, with some cases differing substantially from others. The theme that ties these acts together is the pursuit of payment from the government for fraudulent medical claims.
Common examples of Medicare and Medicaid fraud include:
Submitting False Or Fraudulent Claims
One 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 Claims
Double 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 Requests
Many 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.
The 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 Utah
The 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 Fraud
There 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:
• Healthcare Fraud Statute: This statute applies to both fraudulent claims as well as false statements made to obtain funds from Medicare or Medicaid. A conviction could result in up to 10 years in prison and a fine of $500,000 or double the amount of the fraud, whichever is higher.
• Anti-Kickback Statute: Kickbacks are governed by their own statute. While these penalties are steep, the maximum is lower than the general healthcare fraud statute. A conviction could lead to five years in prison and up to $25,000 in fines.
When 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 Utah
There 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:
• Lack of intent
• Lack of evidence
• Unlawful records seizure
• False allegations
Most Medicare Advantage plans offer the following:
• Hospital coverage. This covers you for hospital visits, nursing facility stays, home healthcare, and hospice care.
• Medical coverage. This covers you for preventive, diagnostic, and treatment-related services.
• Prescription drug coverage. This helps cover some of your prescription drug costs.
• Dental, vision, and hearing coverage. This helps cover yearly screenings and some assistive equipment.
• Additional health perks. This can include additional services, such as fitness memberships.
There are different types of Medicare Advantage plans to choose from, including:
• Health Maintenance Organization (HMO). HMO plans utilize in-network doctors and require referrals for specialists.
• Preferred Provider Organization (PPO). PPO plans charge different rates based on in-network or out-of-network services.
• Private Fee-for-Service (PFFS). PFFS plans are special payment plans that offer provider flexibility.
• Special Needs Plans (SNP). SNPs help with long-term medical costs for chronic conditions.
• Medical Savings Account (MSA). MSA plans are medical savings accounts paired with high deductible health plans.
Personalized plan structures
Medicare 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.
Research 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 care
Many 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.
What are the disadvantages of Medicare Advantage?
Medicare Advantage plans may also have some disadvantages that Original Medicare does not.
Limited service providers
If 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.
Overwhelming plan offerings
While having options is a good thing, it can also be overwhelming, especially when comparing and choosing health plans. Fortunately, you can use a checklist to help you narrow down which Medicare Advantage plans are best for you.
Additional costs for coverage
Original Medicare charges a premium, deductible, and coinsurance for both parts A and B, plus any Part D or Medigap costs. Medicare Advantage plans consolidate these costs into one plan, but you may notice additional fees. For example, drug deductibles and specialist visit co-pays can add up over time with some Medicare Advantage plans.
Original Medicare offers continuous coverage all over the United States. However, most Medicare Advantage plans only offer coverage specific to your service area. This means that if you travel frequently, your Advantage plan may not cover out-of-state services.
Penalties for Medicare or Healthcare Fraud
This is a very complex area of law in that there are many types of charges that can be brought both civil and criminal. Some of the most common sanctions include the following:
• Jail time is very much a possibility. Generally, this can be up to 10 years, but if bodily injury is a component of the claims, this can rise to 20 years.
• Charges of the False Claims Act can result in five years of jail time per occurrence, up to a lifetime for multiple counts.
• Wire fraud can result in up to 20 years of jail time.
• Conspiracy to Commit Healthcare Fraud can provide individuals with up to 20 years in jail
• Monetary penalties are numerous. False Claims Act costs can amount to as much as $250,000.
• Anti-Kickback Statute claims can amount to $50,000 per violation and a fine of three times the amount of the kickback
• Restitution is also common.
• Healthcare fraud claims can equate to $250,000 in fines.
Perhaps most importantly, there is the loss of licensing in a variety of industries. DEA registration loss is also lost. There is also the potential to be excluded from Medicaid or Medicare, suspension of any invoices that are outstanding, and a loss of staff privileges is common.
Common Claims Made Against Medical Professionals
When a medical professional is negligent or engages in misconduct, they can be held liable for their actions. This is done through an investigation conducted by the Office of Professional Medical Conduct (OPMC). These are serious matters, which is why they should not be addressed alone. The second a letter regarding an investigation is received by the OPMC, an experienced medical defense attorney should be contacted. This is because the consequences of misconduct can be severe, calling a professional’s entire practice into question with the potential to lose their medical license. A proper medical defense attorney can assist clients facing the following situations:
• Billing fraud
• Insurance fraud
• Substance abuse
• Medical malpractice
• Sexual misconduct
• Medical license revocation
• Medical license restoration
Medical professionals put a great deal of time and effort into getting their license to practice. Years of hard work can be damaged by the consequences of misconduct. It is because of this that it is crucial to have a medical defense attorney at their side during this trying time. No one wants their life’s work to go to waste due to a mistake. With the help of an attorney, a case can be built to either prove innocence, lessen the charges, or have a medical license restored after it is revoked. The following situations can require the help of a medical defense attorney:
• Investigations by the OPMC
• Disciplinary proceedings between individual healthcare providers and their place of employment
• Restoring medical licenses
• Financial disputes with Medicare, Medicaid, and other billing organizations
Medicare Defense Lawyer In Utah
When you need legal help for medicare defense, please call Ascent Law LLC for your free consultation (801) 676-5506. We want to help you.
8833 S. Redwood Road, Suite C
West Jordan, Utah
84088 United States
Telephone: (801) 676-5506