Medicaid Fraud – What to Look Out For!

Medicaid fraud can be something as simple as lying on your Medicaid application or something more complicated, such as a billing scheme committed by a facility that accepts Medicaid such as a hospital or nursing home. There are many devious ways in which individuals and businesses can scheme to defraud Medicaid, and even as you read this, someone is probably devising a new one. Medicaid fraud basically falls into 2 categories; Provider Fraud and Recipient Fraud.

Medicaid Fraud: Provider Fraud

Provider fraud is when a business that provides Medicaid Benefits to individuals commits Medicaid fraud. The following are just a few ways that providers defraud Medicaid, according to the Office of the Medicaid Inspector General;

Billing for unnecessary services – Ordering and subsequently charging Medicaid for services  or treatments the patient doesn’t need;

“Phantom” Billing – billing Medicaid for services that were never performed, or for dispensing products that the patient never received. Examples of these could be billing for fillings in teeth that were already removed, or medical equipment that was never received;

Multiple Billing – Intentionally sending bills to Medicaid for the same office visit or procedure more than once;

Upcoding- Intentionally billing Medicaid for a more expensive treatment or medication than the patient actually received;

Kickbacks- When Medicaid providers such as hospitals, nursing homes, doctors or dentists give a financial consideration in exchange for business referrals pertaining to Medicaid patients;

Medicaid Fraud: Recipient Fraud

Recipient fraud usually occurs when an individual applying for Medicaid lies on their application by under-reporting income or assets, thereby committing Medicaid fraud. It’s as simple as that; someone applying for Medicaid states they made $3,000 income when in reality they made $20,000. Or they lie about how much money they have in the bank. The Medicaid Office runs an asset check at some point to determine the accuracy of your claims. If you’re off, you can expect that dreaded phone call!