Medicare fraud using fraudulent identities occurs when someone uses another individual’s personal information, like their name, Social Security number, or Medicare number, to submit fraudulent claims for Medicare reimbursement. The US Department of Health and Human Services Office of Inspector General (DHHS-OIG) and the FBI aggressively target and prosecute cases of suspected Medicare fraud involving the use of fraudulent identities.

Common Types of Health Care Fraud

Fraud Committed by Medical Providers

• Double billing: Submitting multiple claims for the same service
• Phantom billing: Billing for a service visit or supplies the patient never received
• Unbundling: Submitting multiple bills for the same service
• Upcoding: Billing for a more expensive service than the patient actually received

Fraud Committed by Patients and Other Individuals

• Bogus marketing: Convincing people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan
• Identity theft/identity swapping: Using another person’s health insurance or allowing another person to use your insurance
• Impersonating a health care professional: Providing or billing for health services or equipment without a license

Fraud Involving Prescriptions

• Forgery: Creating or using forged prescriptions
• Diversion: Diverting legal prescriptions for illegal uses, such as selling your prescription medication
• Doctor shopping: Visiting multiple providers to get prescriptions for controlled substances or getting prescriptions from medical offices that engage in unethical practices

Unfortunately, these investigations can also ensnare individuals who had no criminal intent. Medical billing systems are notoriously complex, and activities that appear fraudulent on paper may have a perfectly legitimate explanation that investigators never bothered to explore.

If you are under investigation or have been charged with Medicare fraud, you need a fierce and tenacious advocate who understands the system, knows how to identify weaknesses in the government’s case, and will work tirelessly to protect your rights, your freedom, and your future.

Understanding Medicare Fraud Investigations

Healthcare providers can seek reimbursement from Medicare for covered services provided to eligible beneficiaries, typically individuals aged 65 or older or those with disabilities. To receive reimbursement, the medical provider must enroll in Medicare and certify that it will comply with all rules and regulations, including not submitting false or fraudulent claims. Once enrolled, suppliers can submit claims electronically, and reimbursement is paid directly to their bank account.

Medicare fraud can occur when a healthcare provider submits claims for services the patient did not need or for items or services that were never provided, or uses another individual’s personal information to submit fraudulent claims for Medicare reimbursement.

Medicare fraud investigations can involve multiple federal agencies, including the FBI, DHHS-OIG, the DOJ Health Care Fraud Unit, and other federal agencies. These agencies review and analyze billing patterns for anomalies, to identify services that were not rendered, and for mismatched information.

Common Charges in Federal Medicare Fraud Cases

Someone under investigation for Medicare fraud using fraudulent identities could be charged under the following statutes:

• Healthcare Fraud (18 USC §1347)
• Aggravated Identity Theft (18 USC §1028(A)
• Wire Fraud (18 USC §1343)
• Money Laundering (18 USC §§1956 and 1957)
• Conspiracy (18 USC §371)

Defending Against Charges of Medicare Fraud Using Fraudulent Identities

As with any criminal case, a charge is not the same as a conviction. Mounting an effective defense will depend on the unique facts and circumstances of your case. Potential defenses to charges of Medicare identity fraud include:

• Lack of Intent. Federal fraud charges almost always require proof of criminal intent. Medical billing procedures can be extraordinarily complex, and coding errors, mistakes, and administrative oversights happen every day. Following standard office procedures, relying on instructions from a supervisor, or simply making a mistake are all potentially viable defenses.
• Mistaken Identity. Federal fraud investigations cast a wide net, and not everyone named in the investigation is equally culpable. Unfortunately, cases of mistaken identity and guilt by association are not uncommon, and challenging the government’s reasons for identifying you as the responsible party is a critical part of a strong defense.
• Statutory Defenses. Each criminal statute consists of specific elements. To secure a conviction, the government must prove each and every element, beyond a reasonable doubt. A defense attorney will carefully review every element of the statute to identify where the government’s case falls short.
• Constitutional Defenses. Federal fraud investigations routinely involve search warrants, wiretaps, subpoenas, and surveillance. For evidence to be admissible, government investigators must strictly adhere to Constitutional requirements. Failure to do so can significantly weaken or collapse the government’s case entirely.

How Federal Criminal Defense Attorney Hope Lefeber Can Help

Medicare fraud is serious, and the penalties for a conviction can be severe. When your rights, your freedom, and your future are on the line, you need a defense attorney who understands federal criminal law, the healthcare billing systems that are at the center of these charges, and who has a proven record of success.

Hope Lefeber has spent more than 30 years defending clients against the most serious federal criminal charges. She represents individuals from all walks of life who are facing federal criminal charges.

Contact the Law Offices of Hope Lefeber

Contact the federal defense law office of Hope Lefeber today. Consultations are free and confidential.