Many physicians mistakenly believe that federal healthcare fraud and abuse statutes only apply to the Medicare fee-for-service program. However, physicians need to be aware that many federal healthcare statutes apply to any program or plan funded, in whole or in part, with federal dollars. One such example is the Medicare Advantage program. Although these plans are implemented by private insurance companies, they are funded with Medicare dollars. As such, they are generally subject to federal healthcare fraud and abuse laws including, without limitation, the federal Health Care Fraud statute and the False Claims Act.
In February 2015, a Florida physician and his medical practice were indicted by a federal grand jury for allegedly engaging in a scheme to defraud the Medicare program through a Humana Medicare Advantage plan. Specifically, the physician and clinic in question are alleged to have submitted fraudulent diagnoses to Humana which resulted in the Medicare program making larger Medicare Advantage capitated payments to Humana. The physician and clinic, in turn, received a larger monthly payment from Humana under the Medicare Advantage Program. Although healthcare fraud cases arising under the Medicare Advantage program are not yet commonplace, this case demonstrates the potential pitfalls associated with federally funded health care programs that all physicians need to be aware of. For more on the indictment, see “Delray Beach Doctor Charged with Health Care Fraud”.