Medicare Fraud Penalty — Everything You Should Know

Fight Medical Fraud Medicare Fraud Penalty — Everything You Should Know

Medicare Fraud Penalty — Everything You Should Know

Federal authorities are increasingly focusing on prosecuting Medicare fraud. The FBI recently apprehended suspects for allegedly defrauding Medicare to a tune of over $1 billion. According to the centers for Medicaid and Medicare services, over 2,100 individuals have been charged with Medicare fraud. Medicare fraud penalty can include jail terms.

However, each form of Medicare fraud comes with a different type of penalty. One of the common types of Medicare medical fraud is upcoding, where medical professionals submit incorrect billing codes to insurance companies to receive inflated reimbursements.

Upcoding and unbundling violate the False Claims Act by defrauding the Medicare federal program. Reporting Medicare fraud and other healthcare fraud can help avoid severe consequences and penalties. This article highlights CPT upcoding and the resulting penalty of Medicare fraud.

What Are Examples of Medicare Fraud?

There are several types of Medicare fraud, including:

  • Performing unnecessary tests/ issuing unnecessary referrals, also known as ping-ponging.
  • Billing for services not provided, in the form of upcoding and phantom billing.
  • Abusing or mistreating patients
  • Charging separately for services typically charged in a package rate, also known as unbundling.
  • Misrepresenting a diagnosis, services provided, a beneficiary's identity, or different facts to justify payments.

Upcoding is among the most common types of Medicare fraud. It involves the manipulation of Current Procedural Terminology (CPT Codes). The consequence of upcoding is increased health care costs for everyone since private payers and the government distribute health care costs among everyone.

What Are the Penalties for Medicare Fraud?

It is illegal to submit payment claims to Medicare that you know are fraudulent or false. Filing false claims results in fines and possibly jail terms as governed by several federal statutes, including:

  1. The False Claims Act
  2. The Start Law
  3. The Anti-Kickback Statute
  4. Federal Health Care Law (18 USC Section 1347).

Besides these statutes applying to payments from the federal governments and healthcare providers, the US DOJ can charge multiple other offenses as a result of Medicare fraud investigation. These include conspiracy charges, mail fraud, wire fraud, money laundering, and other white-collar federal crimes.

Federal Health Care Fraud Law

A standard offense can attract a 10-year prison sentence. It can be increased to 20 years in case of bodily injury or even life imprisonment in case of death. An 18 USC Section 1347 conviction can lead to substantial fines and loss of Medicare eligibility.

False Claims Act

The DOJ can pursue either criminal or civil penalties. Civil monetary penalties under this Act can go over $21,000 per claim, triple damages, and overbilled amount recoupment. In a criminal case, the accused can face up to 5 years in incarceration for each violation and hundreds of thousands of dollars in fines.

However, in both criminal and civil cases under this law, the accused can face loss of hospital privileges, program exclusion, and non-payment of future claims, among other penalties.

Anti-Kickback Statute

This law also includes provisions for civil and criminal penalties. Under civil, one can face civil monetary penalties, program exclusion, fines, triple damages, and recoupment. Criminal fines can attract up to 5 years in incarceration for each offense and up to $25,000 per violation.

Stark Law

It is a civil statute with similar financial penalties to the Anti-Kickback Statute and False Claims Act.

Apart from facing substantial fines and loss of Medicare or hospitalization privileges, here’s a quick look at possible jail time as a penalty of medical fraud:

ViolationJail Time
Federal Health Care Fraud Law10-20 years in prison
False Claims Act5 years
Anti-Kickback Statute5 years
Stark Law5 years

How to Avoid Medicare Fraud Penalty on Your Own

Avoiding Medicare fraud penalties is often as simple as finding and matching the correct CPT codes and writing demand letters for bill correction as soon as possible. You can also report a Medicare billing fraud as soon as possible to be on the safe side of the authorities.

Common ways to avoid such illegal activities and the resulting penalties include:

  • Open and review all bills and statements for accuracy
  • Know and understand your coverage as a patient
  • Handle identity cards carefully since health care identity is rampant
  • Providers should invest in training and education to avoid committing fraud accidentally or intentionally.

How to Avoid Medicare Fraud Penalty with DoNotPay's Help

DoNotPay can help you find the correct CPT Code or write a demand letter for bill correction in a few simple steps:

  1. Search Fight Medical Fraud on DoNotPay.


  2. Tell us the date of your visit, what you were treated for, and where you were treated.


  3. Let us know what CPT code your visit was filed under. If you don't know, we'll generate a letter for you to send to your physician to request the code.


  4. Choose the correct CPT code or let us know if you want us to find it for you.


    And that's it! DoNotPay will automatically find the correct CPT code for your visit if you don't know it and then generate a demand letter on your behalf to send to your physician for a bill correction.


Avoid Medicare fraud penalties by signing up with DoNotPay and finding the correct CPT codes for health care services.

Why Use DoNotPay to Solve CPT Upcoding Challenges?

When you file a report for healthcare fraud with DoNotPay, it is:

  • Faster: DoNotPay works fast around the clock so that you don't have to.
  • Easier: DoNotPay handles the tediousness and tracking of the process.
  • Successful: Rest assured, DoNotPay will make a solid case on your behalf.

What Else Can DoNotPay Do?

DoNotPay's capabilities extend beyond dealing with CPT coding. You can also rely on DoNotPay to help you:

Sign up with DoNotPay to write a demand letter for bill correction and find the correct CPT codes to avoid Medicare fraud penalties ultimately. 

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