What is Medicare?
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are either age 65 and over, or who meet other special criteria.

Who is elegible for Medicare ?
In general, individuals are eligible for Medicare if they (or their spouse) worked for at least 10 years in Medicare-covered employment and are at least 65 years old and are a citizen or permanent resident of the United States of America.

Individuals who are under 65 years old can also be eligible if they are disabled or have end stage renal disease. People under 65 and disabled must be receiving disability benefits from either Social Security or the Railroad Retirement Board for at least 24 months before Medicare automatic enrollment occurs.

What are some examples of Medicare Fraud?

• "Phantom Billing" - Billing for tests not performed.
• Performing inappropriate or unnecessary procedures.
• Charging for equipment/supplies never ordered.
• Billing Medicare/Medicaid for new equipment but providing the patient used or less expensive equipment.
• A drug or equipment supplier completing a Certificate of Medical Necessity (CMN) instead of the physician.
• "Reflex testing" - Automatically running a test whenever the results of some other test fall within a certain range, even though the reflex test was not requested by a physician.
• Offering free services or supplies in exchange for your Medicare or Medicaid number.
• "Double Billing" — charging more than once for the same service, for example by billing using an individual code and again as part of an automated or bundled set of tests.
• "Phantom Employees" - Expensing employees or hours worked that do not exist.
• "Improper Cost Reports" — Submitting false cost reports seeking higher Medicare reimbursements than permitted by actual facts.
• Providing substandard nursing home care and seeking Medicare reimbursement.
• Routinely waiving patient co-payments.

What are the penalties for Medicare fraud ?

The U.S. Attorney General's office targets health care providers for civil and/or criminal prosecution. Some of the penalties for someone convicted of Medicare fraud are listed below.

• The False Claims Act provides fines up to $10,000, treble damages, and up to five years in prison.
• The Anti-Kickback provisions of the Social Security Act provide for fines of up to $25,000, and up to five years in prison.
• Civil monetary penalties provide for fines up to $50,000 and treble damages.
• RICO — the Racketeering Influenced and Corrupt Organization Act — has recently been used in Medicare fraud cases. Those convicted criminally can get prison terms of up to 20 years. Civil conviction under RICO provides for asset forfeiture.
• The Health Insurance Portability and Accountability Act, often called Kassebaum-Kennedy, created a new crime called Health Care Fraud. This crime allows up to 10 years in prison, or up to 20 years if serious bodily injury results, or up to life in prison if death occurs.
• In addition to these penalties, the Department of Health Services can also exclude a health care provider from the Medicare system.

Kuniansky & Associates
The Lyric Centre
440 Louisiana , Suite 200
Houston, Texas 77002
Office: 713-622-8333
Fax: 713-224-2815