Medicaid Fraud

Medicaid Scams steal money from those that need it most, both patients and the people that provide health care services.

The Medicaid plan is intended to impart health care to the poor by using tax dollars to pay the medical bills of low-income people. Receiving these funds is life or death for many Americans the hope is that the money is managed wisely so that the most good reaches the most people. Sadly, some Medicaid suppliers and Medicaid recipients abuse the system by engaging in an assortment of scams.

What Medicaid Fraud Does

Medicaid Fraud has far-reaching effects that touch almost everyone whether it’s the people in need of health care, honest providers of health care and then finally you the taxpayer. Every time a patient files a claim fraudulently and each time a provider bills more than they should they are taking money away from those that need it. If you know anyone defrauding the Medicaid system you must report it immediately. Below are many forms of Medicaid abuse that you should be on the lookout for.

Medicaid Scams

Medicaid Recipient Fraud

Most people receiving Medicaid services do so legally within Medicaid guidelines. However, a small group of folks abuse their rights and participate in deceptive behavior. The agency responsible for investigating Medicaid recipient use and other claims of fakery is the U.S. Health Department’s Office of Medicaid Management. There are types of fraud, like prescription drug forgery, that if found during their investigations, the Office of Medicaid Management will turn over to other agencies for follow up and prosecution.

Cases of Medicaid Recipient Fraud

Medicaid user fraud comes is a few different flavors and isn’t always obvious. That’s why both providers and users need to be conscientious and work together to identify fraudulent activity. Examples of Medicaid user fraud include:

  • The loaning of Medicaid ID cards to others.
  • Changing or faking an order or prescription.
  • Utilizing more than one Medicaid identification card.
  • Deliberately getting conflicting, duplicate or excessive services and/or supplies.
  • Selling supplies given by Medicaid to others, instead of using them yourself.

If you suspect that a recipient has engaged in any of the activities listed above or any other questionable activity, please call 1-877-87FRAUD. Your call will remain confidential.

How to Report Recipient Fraud

If you believe a Medicaid user has participated in any of the actions listed above or any other dubious activity, please call 1-877-87FRAUD. You can choose to make your statement anonymously.

Medicaid Provider Fraud

Less prevalent but no less damaging, Medicaid supplier fraud does occur. Again, as in Medicaid user fraud, the agency in charge of Medicaid supplier oversight is the Office of Medicaid Management. They review billing, other supplier actions, investigate any claims that Medicaid suppliers are behaving fraudulently and mete out justice when following through on any legal consequences.

Cases of Medicaid Provider Fraud

As stated above in the Cases of Medicaid Recipient Fraud, provider fraud also comes in several different flavors. And again, is why both users and suppliers must work together to identify any fraudulent activity perpetrated by Medicaid suppliers. Ways to assist the Office of Medicaid Management in identifying fraudulent activity include keeping records on the following items:

  • When you received service from a Medicaid professional.
  • Where the service took place.
  • Who the professional was who provided care to you.
  • Which services were given during the visit.
  • Any additional services ordered by the provider.

Any services billed that weren’t actually provided are considered fraud and need to be reported.

Examples of Medicaid supplier fraud include:

  • Services billed yet not given, such as a chest x-ray or lab work.
  • Billing sent to both the Medicaid program and a private insurance entity or the Medicaid user.
  • Calling for the Medicaid user to come back to the supplier’s office, even when it’s obvious additional appointments are not necessary.
  • Ordering unnecessary services like x-rays, blood work, ultrasounds, etc.
  • Incorrect coding, i.e., supplying just a regular office visit but billing for something more.
  • Using unauthorized suppliers for the services that only authorized professionals should give and then billing them as if the authorized supplier gave the services.
  • Providing a set amount of services based on time and then billing for more time than was really provided, i.e., anesthesia, counseling, etc.
  • Adding other family members to bills as receiving services when they didn’t.
  • Sending in a bill for office visits that didn’t actually occur.
  • When referring a patient to another supplier, the first provider takes payment from the other supplier, which may include part of the reimbursement paid to the second provider by the Medicaid program.

How to Report Medicaid Provider Fraud

If you believe a Medicaid supplier has participated in any of the actions listed above or any other dubious activity, please call 1-877-87FRAUD. You can choose to make your statement anonymously.

Some Examples of Medicaid Fraud

This is only a partial list of some of the medical-related fraud out there. Many of these types of medical fraud target seniors but anyone can be a victim.

  • Hearing Aids – Millions of Americans have trouble hearing. Many could benefit from some type of hearing aid, but some may not. How do you know if you’re one of the lucky ones? Once you’ve decided to try one, you visit a qualified audiologist or seller to be fitted. Make sure you inquire about free trial so that you can test the hearing aid. Ask about and gather information about guarantees and warranties. Make there are in writing and not simply verbal agreements.

    Regulations that cover many important aspects of hearing aid sales for consumers are enforced by the U.S. Food and Drug Administration. One regulation requires that you are told about the need for a medical evaluation by a physician before you buy an aid; another requires that aids come with instruction books covering use, maintenance, and repair.

  • Switching Prescriptions – In the past few years, many prescription drug companies have formed business relationships with pharmacy groups and insurance companies that handle drug-benefit plans. In some cases, pharmacies and insurers receive rebates or other financial incentives when they convince a plan member to switch to a different drug made by a “partner” manufacturer. If you are uncomfortable about making a switch, call the Food and Drug Administration, your local Department of Health, or your local Board of Pharmacy. They can help you decide whether it makes sense to change your medication.

    Meantime, you may want to ask your pharmacist or physician a few important questions: Will the new drug work as well for your condition? Are there different side effects or risks? Are the dosage levels the same? Is there a business connection between the pharmacist and the drug manufacturer? Will the switch save you or your benefit plan money or cost you money?

  • Nursing Homes – Residents should be able to complain and complaint procedure policy should be clear. If you feel the need to file a complaint, ask a sympothetic staff member how you should go about it. You also may want to ask the nurse in charge to review your family member’s care plan. If you still are uncomfortable with the situation, speak to the director of nursing, the social worker, or the administrator or check to see if the nursing home has a family council, a group of advocates who try to improve the quality of life in the home.

    Often, nursing homes operated by large corporations have toll-free telephone numbers you can use to speak to a regional supervisor.

  • Alternative Medicines – Many unconventional treatments for cancer and other diseases are on the market. A few have undergone rigorous scientific testing for their curative value. Many that have been tested don’t show effectiveness. Still, some forms of alternative therapy are recognized as helpful in caring for patients and helping them cope with some illnesses.

    Usually, a primary care physician is the best source of information about alternative medicine as a supplement to conventional treatments.

    If someone tries to sell you an alternative treatment by promising that it is effective, ask for a copy of the studies that prove it. Then ask your primary care physician or family doctor to review the studies to determine their credibility.

    If you think you’ve been misled by advertisements for either alternative medicine or conventional treatments, be cautious and complain.

  • Cataract Surgery – Cataracts come with age; they usually develop over time and don’t have to be removed immediately. You generally can wait to have the surgery until your vision begins to bother you.

    If your doctor says you have a cataract, ask if the surgery can be put off or whether it needs to be operated on immediately. If you’re advised to have surgery ask your doctor how risky it is. Are you healthy enough to go through it?

    If you’re told there’s no risk involved or are guaranteed to come out of it successfully, you might want to get a second opinion. Serious complications are rare, but when they do occur, they could result in loss of vision.

  • Arthritis Cures – The U.S. Department of Health and Human Services’ National Health Information Center can help you get in touch with public and private groups that have information about traditional and alternative therapies for arthritis and other conditions. Your public library also may have a computer link to provide you with direct access to the National Health Information Center. To learn which products are government approved and which aren’t, call the FDA. For the latest information on vitamins and nutritional supplements, call the FDA’s Center for Food Safety and Applied Nutrition.
  • Direct-Mail Scams – Many direct mail marketers use trickery to help sell their products. Some disguise their ads by dressing them up as “clippings” sent by unidentified friends. These friends don’t exist. The direct marketer got your name from a mailing list and sent the “clippings” to thousands of people.

    Disguising marketing materials as checks or official government notices is also a common tactic. One of my favorites involves advertising that arrives in envelopes stamped with the words “urgent” in big red letters.

    If the company sending out these marketing materials is using trickery to get you to look at them, how much do you think you can trust the offers inside. Think about it. Report any questionable solicitation you receive in the mail to your local Postmaster or Postal Inspector. Check the phone book for the phone number.

  • Abusive Care-givers – No one should be abused, physically or verbally, by anyone, including family members or care-givers. Everyone has the right to feel safe and secure in their own home. If you or someone you know is being abused in any way, report it. Everyone has the right to be protected.

How you can help in the fight against Medicaid fraud.

Medicaid Fraud ends up costing us all in the form of higher insurance premiums and taxes. Here’s what you can do to help fight Medicaid Scams.

  • Review your Medicaid bill when you receive it. Did you receive each service and all supplies listed on the invoice? Are the dates correct?
  • Only give your Medicaid number to those needing it. (Doctors, hospitals, clinics, etc.)
  • Don’t lend your Medicaid card to anyone. If anyone uses it in your name they are committing a crime.
  • Never request medical services or equipment you don’t need.
  • Don’t sign blank forms for medical services or equipment.
  • Request and retain copies of anything you sign.
  • Only share Medicaid and your medical information with those needing it. (Doctors, hospitals, clinics, etc.)
  • Be wary of offers for free testing and medical screenings, especially when the services are covered by Medicaid.
  • Never give out your Medicaid information to telemarketers or door-to-door salesmen pushing free medical services or equipment. Why would they need your Medicaid number?
  • Only supply those you’ve received medical care or services from access to your Medicaid ID card.
  • Never let medical providers bill Medicaid for services before contacting you.
  • Ignore fantastic claims made about Medicaid paying for medical care or services everyone knows they don’t cover.

9 Responses

  1. AMW says:

    I filed a complaint about the Nursing Home I was in as a patient . I was forcibly evicted 4 days later without any warning. I was in a wheelchair, in pain, with no place to go. All of my belonging were evicted as well. The DON/owner/administrator tried to force me to sign an AMA form. I refused so he signed for me. He refused calling a. Doctor or Social Worker. He just put me in the parking lot and left me there.

  2. Jeannie Ledford says:

    if a person is getting narcotics with Medicare selling them illegally is that fraud

  3. Laney says:

    Is it Medicaid fraud to have a BA or an individual without a degree to provide services on cases that are receiving intensive services such as CPST and PSR or Intensive Family Services only without a licensed or MA person working the case also?

  4. Sheila Dixon says:

    If someone is selling food stamps, where can I report it?

  5. LVT says:

    Reported individual selling food stamps several times over the last 3 years (Illinois). No action taken, still receiving and selling food stamps.
    Same individual uses medicaid benefits to obtain narcotics which are then sold, for at least 4 years. Again, no action taken. Governments say they have to cut programs, but are giving away too much to people like this.

  6. Cmd says:

    If a person has been living in Pennsylvania for over 5 months, and is still using their NYS Medicaid card for services is this illegal?

  7. Joe says:

    I live in California. Does anyone actually investigate the people who are accused of welfare fraud or is it a waste of time?

  8. Jen says:

    How can a mother, receiving $1600 a month in child support/spousal support, 2 children ages 8 and 13, who has a live in, receive Medicaid for her children? She is not disabled, just doesn’t work, and her ex husband has requested to put them on his private insurance policy.

  9. time2takeoutthetrash says:

    My soon to be ex-husband’s girlfriend and their baby is from Wyoming. However, they have been living in Montana with him for at least 8 months. She travels back to Wyoming for drs appts since she’s on Wyoming Medicaid. Isn’t that fraud? She also collects food stamps and other government benefits while living here in Montana. I believe in working for what you have. This woman however does not. She has no problems sleeping with a married man or destroying his family. Moving into his family home or living off the government. Any information would be helpful.

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