Medicare Fraud

In the United States, Medicare fraud is the claiming of Medicare health care reimbursement to which the claimant is not entitled. There are many different types of Medicare fraud, all of which have the same goal: to collect money from the Medicare program illegitimately. The total amount of Medicare fraud is difficult to track, because not all fraud is detected and not all suspicious claims turn o... en.wikipedia.org

In my experience as an attorney with more than 34 years experience, the difficulty in proving that the government should not have paid the claim entirely rests with the government.  There are many aspects to Medicare fraud that is not fraud per say because the intent is not to be unfairly compensated, but to be compensated in the way that the claimant is entitled to.  Challenges to Medicare's interpretation and practices can be levied because the definitions are broad and their explanations can be mis-interpreted or are out of date.

We have seen instances of minor players in Medicare schemes unaware of the ramifications of the activities they engage in since their employer or superior has requested they do so without their knowledge.  Medicare offices are similar to social service agencies, hence do not have the same practices as private companies, and may make mistakes or misinterpret the claimant's intent.

There are many defenses regarding Medicare fraud.   Sometimes the lack of knowledge, or even being told otherwise by a superior or boss, has led to a Medicare fraud investigation.  Insurance agents can be helpful in these cases because they know the extent to which the covered Medicare policy may be enforced if there is one available.