What is Medicaid Fraud?
Medicaid providers include doctors, dentists, hospitals, nursing homes, pharmacies, clinics, counselors, personal care/homemaker chore companies, and any other individual or company that is paid by the Medicaid program. If a Medicaid provider intentionally misrepresents the services rendered, and therefore increases their reimbursement from the State Medicaid plan, Medicaid fraud has occurred.
Some Medicaid providers engage in fraudulent (unlawful) activities. The Office of the Medicaid Inspector General reviews medicaid provider billing and other activities and investigates charges of fraudulent behavior in order to take all appropriate actions.
- Billing for services not actually performed, known as phantom billing to Medicaid;
- Billing for more expensive services than was actually rendered, known as up-coding;
- Billing for several medical services that should be combined into one billing, known as un-bundling;
- Billing twice for the same service;
- Dispensing generic drugs and billing for brand name drugs;
- Giving or accepting something in return for services, known as a kick-back;
- Bribery;
- Providing unnecessary medical services;
- False services cost reports; and
- Embezzlement of recipient funds.
Medicaid Fraud
Medicaid fraud can come from both providers and recipients. Some Medicaid recipients engage in fraudulent behavior and abuse their privileges. Medicaid fraud investigators reviews recipient utilization and investigates other charges of fraudulent behavior in order to take appropriate actions. Some types of recipient fraud, such as forging prescriptions, are subject to criminal prosecution and will be referred to the appropriate state law enforcement authorities.
Medicaid Fraud can take on a variety of appearances. From purely a fraud perspective, it can be described as any effort to defraud the state Medicaid system by billing for services not delivered, or under-delivered. It can also show itself in cases where physical abuse or neglect has occurred. This includes, but is not limited to, battery, assault and failure to deliver services or medications. In either case, in order for there to be Medicaid Fraud, Medicaid funded money must be involved.
State Medicaid fraud can take many forms. You can avoid being taken advantage and being a victim of by unscrupulous individuals by watching for the following:
- Payments (in cash or in kind) in return for Medicaid numbers,
- Every patient in a group setting receiving the same type of service on the same day,
- Every patient in a group setting receiving the same type of medical equipment, and
- Services listed on your medical summary notice that you don’t remember receiving or didn’t need.