What Triggers a Medicare or Medicaid Billing Fraud Investigation?

Website By Law Offices of John Howley, Esq., New York
Firm's Profile & Articles Law Firm's Profile & Articles
Phone Call (212) 601-2728Free ConsultationFree Consultation
Medicare and Medicaid billing mistakes can result in a fraud investigation with potentially serious consequences. You can be required to pay back up to three times the amount you were paid for improperly billed services. And, if the government believes the improper billing was intentional, you can face serious criminal charges, the loss of professional licenses, and exclusion from the Medicare and Medicaid programs.

Medicare and Medicaid are incredibly complex programs. It is not unusual for even experienced providers and billers to make mistakes. Too often, those mistakes lead to fraud investigations and even criminal charges.

Here are the most common types of Medicare and Medicaid billing issues that can trigger a fraud investigation:

Phantom Billing

One of the most common forms
of Medicare and Medicaid fraud is billing for services or supplies that were never provided to the patient.

No Medical Necessity

Medicare and Medicaid only pay for services and supplies that are “medically reasonable and necessary” for the diagnosis or treatment of an illness or injury. Even if a service is determined to be "reasonable and necessary," however, the government may accuse the provider of fraud if the medical necessity is not properly documented or the service is provided more frequently than permitted.


Billing for more expensive services or supplies than actually provided is called “upcoding.” While the practice is difficult to catch, the government is often alerted when a patient changes providers, a former employee turns into a whistleblower, or the volume of supplies claimed is significantly higher than the volume purchased from wholesalers.


The most common form of “unbundling” is billing separately for services that should be billed together. It also refers to the practice of claiming that services provided during a single office visit were provided on different dates in order to obtain a higher reimbursement rate.

Double billing

The meaning of “double billing” may seem obvious, but it can actually take a number of different forms. The practice includes billing both government programs and private insurance for the same services or supplies, billing twice for the same service by using both an individual code and a bundled code that includes the individual service or supply, and two providers billing for the same service to the same patient when only one actually provided the service.

Billing for Ineligible Practitioners

Medicare and Medicaid only reimburse for services provided by a properly licensed and certified professional. If the healthcare provider did not have the necessary licenses and certifications, or if they were on a state or federal “exclusion list” at the time the services were provided, then the claim for reimbursement may be considered a “false claim” under the False Claims Act.

Prescription Fraud

Knowingly writing, obtaining, altering, or filling a prescription for drugs that are not medically reasonable and necessary is a serious crime that can result in a long prison sentence. While prescription fraud happens most often with opioids and other drugs that can be re-sold to addicts, the prohibition applies to all prescription drugs. Maintaining detailed records of patient examinations and test results justifying the prescriptions is critical to your defense.

ABOUT THE AUTHOR: John Howley, Esq.
John Howley has more than 25 years of experience representing healthcare providers, pharmaceutical and biotech companies, medical device companies, and durable medical equipment providers in government investigations, complex litigation, and criminal trials.

Copyright Law Offices of John Howley, Esq. - Google+
More information from Law Offices of John Howley, Esq.

Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer. For specific technical or legal advice on the information provided and related topics, please contact the author.

Find a Lawyer

Find a Local Lawyer