February 03, 2020

Things that trigger a Medicare or Medicaid fraud investigation

Medical costs in the United States have spiraled upward at an alarming rate — and you can bet that prosecutors are paying close attention to this political “hot button.” Indeed, the Office of the Inspector General goes out of its way to raise public awareness about Medicare and Medicaid fraud, collect tips related to potential fraud and publish information about related criminal convictions.

The most critical thing that physicians and medical practices need to understand is this: You don’t have to intentionally commit Medicare or Medicaid fraud to trigger a government investigation.

What sort of issues can start your practice down the road toward a fraud investigation?


Every time you bill, you have to attach a billing code — and that code determines how much your practice will be reimbursed. Since there are thousands of codes, it’s far too easy to accidentally use an improper code. A sprained arm, for example, could be mistakenly coded as a broken arm.


Imagine this: A patient comes into your rheumatology practice for a regular visit and asks to get steroid shots in her knees. The shots should be bundled together with the office visit, at a special price. Instead, the billing office bills for the office visit and the steroid shots as if they were done at different times, increasing the profitability — but puts you at risk of an audit.

Double billing

While there are providers who do this purposefully, it can also happen by accident. When a patient has private insurance in addition to his or her Medicare entitlement, it’s easy for the billing department to make a mistake.

Unnecessary services

Providers and the government don’t necessarily agree on what is “medically necessary” services or treatment. Again, some providers do run unnecessary tests and perform unnecessary procedures on patients to drive up their bills — but sometimes the government will come down hard on a provider whose documentation regarding something’s medical necessity is just lax or missing.

Being the subject of a Medicare or Medicaid fraud investigation can disrupt your practice, upend your life and ruin your reputation — even before charges have been filed. Find out how to protect your legal interests.

Contact Us

For a free confidential consultation, fill out the form below.

Fields marked with an * are required

"*" indicates required fields

I Have Read The Disclaimer*

Pietragallo Law Firm Recognitions