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5 Examples of Medicare Fraud

One of the most widespread manifestations of fraud related to government programs is Medicare fraud. This is considered a federal charge and can carry hefty penalties, such as fines that total up to three times the amount of damage caused. The False Claims Act, which makes it a federal crime to overbill the government, is one law from which many Medicare defendants are charged. Below, we have outlined five common ways medical professionals commit Medicare fraud.

  1. Upcoding. This is among the most common examples of Medicare fraud. With this practice, a hospital, doctor’s office, or other medical institution changes billing codes (set by the American Medical Association) in order to receive a higher payment amount than is warranted. Some providers may upcode in order to make it appear as if their profits are higher than they actually are, or the billing party may simply want to pocket the extra money.
  2. Durable medical equipment fraud. Materials referred to as durable medical equipment are items that are meant to be used for extended use (more than a few days). Wheelchairs, crutches, and hospital beds are some examples of durable medical equipment. There are many ways you can commit durable medical equipment fraud, but two common ways are billing for such equipment that isn’t medically necessary or purposely providing defective equipment.
  3. Illegal kickbacks. The federal Anti-Kickback Statute prohibits physicians from making referrals to federally funded institutions in exchange for compensation. This is a form of bribery and is prosecuted under the False Claims Act.
  4. Billing for services that weren’t provided. This is often referred to as “phantom billing.” A phantom bill is an invoice for services that were never actually rendered for a patient. Along with upcoding, this is one of the most common types of Medicare fraud. Another type of fraud that is similar to phantom billing is to bill for services that were performed, but not medically necessary.
  5. Stark Law violations. Doctors are limited in their referral options. To combat a specific type of Medicare fraud, the Stark Law prohibits physicians from referring a patient to a particular medical institution or for a medical procedure that the referring physician has a financial interest in. The term for this type of fraud is “physician self-referral.”


There are a number of agencies tasked with investigating Medicare fraud. The federal government does not take such charges lightly, and it is important to quickly retain the services of a knowledgeable white-collar defense attorney to fight those charges. Petkovich Law Firm would be proud to take on your Medicare fraud case; call us today at 305-358-8003 to get started with a consultation.


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