Federal Medicare Fraud

New Jersey and Federal Medicare Fraud

Medicare fraud refers to an individual or corporation that seeks to collect Medicare health care reimbursement under false pretenses. There are many different types of Medicare fraud, all of which have the same goal: to collect money from the Medicare program illegitimately.

Medicare is a federal program and is commonly prosecuted in federal Courts.  There are however prosecutions in New Jersey State courts under the general theories of Theft, in violation of 2C:20-3, or Theft by Deception, in violation of 2C:20-4.

Medicare Recipient Fraud

In order to qualify for Medicare, a person must meet certain income and asset requirements. Through creative estate planning, some people can legally transfer assets to family members and other in order to qualify. However, others mislead Medicare by falsifying their application. An asset check may uncover this deception led to an investigation. Medicare recipients have also been arrested for selling items purchased by Medicare such as wheelchairs or taking kick backs from providers.

Medicare Provider fraud

Medicare provider fraud is very common and investigations target doctors as well as suppliers. Medicare provider fraud can include: billing for services that were not provided (e.g., x-ray that was not taken); duplicate billing, either billing Medicare twice or billing Medicare and private insurance; requiring the recipient to return for more visits than what is necessary; unnecessary tests and treatment; upcoding, (e.g., billing for a long, comprehensive visit for just a short, simple visit); having an unlicensed person perform services that only a licensed professional should render; billing for more time than actually provided; billing for an office visit that did not actually occur; accepting payment from another provider as a result of referring a patient to the other provider, otherwise known as a kick back; waiving copayments or deductibles.

Provider fraud can result from high pressure sales tactics to get the recipient to accept expensive equipment or services that are unnecessary, offers non-medical transport and bills it to Medicare, offers housekeeping and bills it to Medicare, billing Medicare for equipment to people in nursing homes, kickbacks to recipients or other providers for accepting the suppliers goods or services, billing Medicare for wheelchairs, scooters and other equipment when the recipient does not qualify and billing Medicare higher fees than non-Medicare customers.

Federal Medicare Fraud Penalties

In 1987, the United States Sentencing Commission presented its Sentencing Guidelines. One of the goals of the Sentencing Commission was to bring about tougher sentencing for “White Collar crimes”. Even the most minor White Collar felonies would draw incarceration under the guidelines. Until 2005, these guidelines were mandatory, then the U.S. Supreme Court’s decision in U.S. v. Booker changed the rules and held that the sentencing guidelines are now advisory in nature (in other words, the judge has much more discretion).

The sentencing guidelines assign a numerical offense level (ranging from number one to number forty three) for every Federal offense. Level one is the lowest, and level forty three is the highest (i.e., a level forty three results in life imprisonment).

Federal Medicare Fraud offenses are automatically given a base offense level of seven or six. In addition, there is an increase in a sentencing level depending on the amount of monetary loss (for example, $5,000 or more adds two levels; $10,000 or more adds four levels; etc. all the way up to $400,000 or more-which adds thirty levels. Also, additional levels are added for a multitude of other factors (such as number of victims, whether mass mailing was used, whether there was a misrepresentation that the defendant was acting on the behalf of a charitable group of Governmental agency, whether $1,000,000 in gross receipts were obtained from one or more financial institutions, whether it involved the violations of security law and the defendant was an officer or director of a publicly traded corporation, etc.). A standard example with minimum aggravators would involve a defendant with no prior significant record who was accused of taking more than $200,000, (but less than $400,000) would be assigned a base level of nineteen, which would result in a sentence of thirty to thirty seven months in prison. However, the guidelines also provide for a number of adjustments that can either increase or decrease an offense level. This means that a judge can tailor a particular sentence to a defendant based on the factors set forth in 18 U.S.C. §3553(a).

Since the advent of Booker, the court is obligated to consider the individual circumstances of each particular case and then render a sentence “sufficient, but not greater than necessary” for an individual defendant, both in light of the sentencing guidelines and the factors set forth in 18 U.S.C. §3553(a).

Although the judge cannot dictate where a sentence will be served, he can recommend to the Bureau of Prisons where the sentence should be carried out. They normally will attempt to follow the judge’s recommendation. Where a Defendant is incarcerated is obviously important due to access to family, medical treatment, and overall quality of life.

Federal Medicare Fraud Statutes

18 U.S.C.A. § 1347. Health care fraud

(a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice–

(1) to defraud any health care benefit program; or

(2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program,

in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.

(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.


(Added Pub.L. 104-191, Title II, § 242(a)(1), Aug. 21, 1996, 110 Stat. 2016; amended Pub.L. 111-148, Title VI, § 10606(b), Mar. 23, 2010, 124 Stat. 1008.)

18 U.S.C.A. § 287-False, fictitious or fraudulent claims

Whoever makes or presents to any person or officer in the civil, military, or naval service of the United States, or to any department or agency thereof, any claim upon or against the United States, or any department or agency thereof, knowing such claim to be false, fictitious, or fraudulent, shall be imprisoned not more than five years and shall be subject to a fine in the amount provided in this title.


(June 25, 1948, c. 645, 62 Stat. 698; Oct. 27, 1986, Pub.L. 99-562, § 7, 100 Stat. 3169.)

Other Types of Fraud Crimes in Federal District Court


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