Medicaid and Medicare were originally put in place to assist the most at-risk Americans. This makes the prevalence of Medicaid fraud even more alarming. From nursing home abuses to the sale of defective drugs, Medicaid fraud comes in many different types, and each of these practices can cause considerable harm not only to patients, but also to the medical system as a whole.

If you work for a company that makes claims through Medicaid, and you believe your employer may be wrongfully making claims or taking other improper actions, you can file a whistleblower complaint alleging Medicaid fraud. This may feel like a risky decision given the fact that you are employed by the bad-actor, but the government has many protections in place for whistleblowers that ensure the employee will not face retributive action and encourage employees to come forward by offering significant awards.

What Is Medicaid Fraud?

According to the National Whistleblower Center, Medicaid fraud involves making fraudulent reimbursement claims. The most common types of Medicaid fraud involve overbilling either for unnecessary procedures, procedures that were never performed, or for unnecessary equipment. This can occur either in federal or state-administered health care programs. A whistleblower complaint can be made for either type of health care system and aims to recover wrongfully billed money.

Medicaid Fraud is committed by medical providers: dentists, doctors, hospitals, hospice care providers, or nursing homes. These offenses violate the False Claims Act, a law put in place in 1863 to protect the government from fraud. Since the False Claims Act was put in place, Medicaid fraud investigators have become increasingly in demand.

Medicaid Fraud Investigator

According to an interview of Dr. David Botsko, former Medicaid fraud investigator and current trainer of Medicaid fraud investigators, by Thomas Reuters, every state in the country is required to have a Program Integrity section, a division set up to investigate Medicaid fraud. Each state is required to have units for investigation and auditing, but these units vary from state to state. The tools these teams use to investigate Medicaid fraud have improved significantly in the last few years and now an investigation that would have taken “40 hours now takes 30”.

According to the U.S. Department of Health and Human Services, those who investigate Medicaid fraud are known as the Medicaid Fraud Control Units (MFCU). These units “investigate and prosecute Medicaid provider fraud as well as patient abuse or neglect”. Currently, there is an active MFCU in each state, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. These units are generally a part of the state’s Attorney General’s office and include investigators, attorneys, and auditors.

Medicaid Fraud Examples

As stated above, the most common type of Medicaid fraud is overbilling, but there are many more types committed every year. According to the Centers for Medicare and Medicaid Services, there are ten main types of Medicaid fraud:

• Billing for unnecessary services or items

• Billing for services or items that were not provided

• Unbundling, or billing for multiple codes rather than a single global code covering a group of procedures

• Upcoding, or billing for a higher level of complexity than the service provided

• Card sharing, or “knowingly treating and claiming reimbursement for someone other than the eligible beneficiary”

• Collusion, or filing false claims by collaborating with beneficiaries

• Drug diversion, or prescribing unnecessary prescriptions including prescribing drugs for personal use or to sell

• Kickbacks, or receiving beneficiary referrals for medical services in exchange for pay or other forms of solicitation

• Multiple cards, or “knowingly accepting multiple Medicaid ID cards from a beneficiary to claim reimbursement”

• Program eligibility, or billing an ineligible beneficiary with the knowledge that they are ineligible

This article is not legal advice. It is presented
for informational purposes only.