What is Medicaid Fraud?

Do You Have Information About Medicaid Fraud? Here’s What You Need to Know

Medicaid fraud is a major problem. It costs U.S. taxpayers not just millions, but billions of dollars per year. Medicaid fraud also compromises the quality of patient care, and state and federal law enforcement authorities are forced to devote substantial resources (also funded by taxpayers) to uncovering fraud, waste, and abuse.

With this in mind, if you have information about Medicaid fraud, it is important that you consider coming forward.

The Basics of Medicaid Fraud

So, what is Medicaid fraud? Simply put, Medicaid fraud involves improperly obtaining reimbursements under the Medicaid program. As discussed below, it can take numerous specific forms, and many healthcare providers and other businesses have become extremely skilled at submitting improper (and fraudulent) claims while evading detection. This is why it is important for whistleblowers to come forward. In many cases, government authorities simply cannot detect Medicaid fraud on their own.

Medicaid fraud violates several laws, most notably the federal False Claims Act. The False Claims Act makes it a federal fund to submit any “false or fraudulent claim” for payment from the government. If a business or individual receives money from Medicaid that it isn’t entitled to receive, this constitutes Medicaid fraud. Inadvertently overbilling Medicaid is a civil offense, while intentionally defrauding Medicaid is a federal crime that carries fines and prison time.

Common Examples of Medicaid Fraud

Here are some all-too-common examples of Medicaid fraud:

Double Billing

Double billing Medicaid for services provided to program beneficiaries is a clear form of fraud. This includes both billing Medicaid twice and billing Medicaid in addition to another payor.

Billing for Medically Unnecessary Services

Medicaid only covers medically necessary services, as determined by a patient’s symptoms, test results, and other relevant medical factors. Relying on a patient’s Medicaid benefits to seek payment for other services is a clear form of fraud as well.

Billing for Non-Covered Services

While Medicaid covers medically necessary services, it does not cover all medically necessary services. If a Medicaid patient sees a physician for treatment not covered under Medicaid, then billing Medicaid is improper.

Billing for Services Not Rendered

From diagnosis to treatment, billing Medicaid for services not rendered is an alarmingly common Medicaid fraud scheme. If a healthcare provider bills Medicaid for any test, procedure, or service not actually provided, this “phantom billing” violates the law.

Paying or Accepting Fees for Patient Referrals

Federal law prohibits healthcare providers and other entities and individuals from paying referral fees, gifts, or other “remuneration” out of Medicaid funds (directly or indirectly). These “kickbacks” violate the False Claims Act and other federal laws.

Using False Information to Support Medicaid Billings

Falsely representing patients’ Medicaid eligibility, misrepresenting non-covered services as covered services, and other means of using false information to support Medicaid billings are all common forms of fraud as well.

Companies that Can Commit Medicaid Fraud

Here are some examples of companies that can commit Medicaid fraud:

Clinics and Laboratories

Clinics and laboratories can (and do) improperly bill Medicaid for blood work, X-rays, and other diagnostic tests and services. In some cases, these facilities improperly offer kickbacks in exchange for patient referrals as well.

Doctors’ Offices and Hospitals

Doctors’ offices and hospitals can face accountability for improperly billing Medicaid through all of the means listed above. Fees and other forms of compensation paid in return for Medicaid patient referrals are an issue here, too.

Managed Care Organizations

Managed care organizations can face accountability for Medicaid fraud on various grounds. The extent to which a managed care organization and its executives are aware of and involved in Medicaid fraud will determine what penalties are on the table.

Durable Medical Equipment Suppliers

Durable medical equipment suppliers can be held accountable for improperly billing Medicaid and offering compensation or discounts for purchasing their x-ray machines and other equipment.

Pharmaceutical Companies and Pharmacies

Pharmaceutical companies can (and do) commit forms of Medicaid fraud similar to DME companies. Pharmacies and pharmacists that engage in improper billing and referral practices can also face civil or criminal liability under the False Claims Act.

Other Companies that Obtain Funds from Medicaid

Along with these (and other) entities in the healthcare industry, various other companies can be held accountable for Medicaid fraud as well. Other companies that can obtain funds from Medicaid—both properly and improperly—include:

• Autism centers
• Daycare centers
• Dentists’ offices
• Nursing homes
• Transportation providers

These, too, are just examples. If you suspect that any company or individual may have improperly received funds from Medicaid, we strongly encourage you to speak with one of our attorneys about coming forward.

How the Government Fights Medicaid Fraud

Fighting Medicaid fraud is a constant battle at both the state and federal levels. State and federal authorities deal with incidents involving Medicaid fraud every day—and these incidents represent just a small fraction of the scope of the problem. The primary authorities involved in the government’s ongoing fight against Medicaid fraud are:

Medicaid Fraud Control Units (MFCUs)

Medicaid Fraud Control Units (MFCUs) are state-level law enforcement agencies. They investigate cases of Medicaid recipient fraud when possible, and they work alongside federal authorities in many cases. Since Medicaid programs are typically administered at the state level, MFCUs are often the first point of contact when program administrators notice billing irregularities.

U.S. Department of Health and Human Services (HHS)

The U.S. Department of Health and Human Services (HHS) is primarily responsible for enforcing Medicaid compliance, and its Office of Inspector General (HHS OIG) has the authority to investigate healthcare providers and other entities suspected of engaging in Medicaid fraud. The Centers for Medicare and Medicaid Services (CMS), which is part of HHS, also has the authority to audit participating providers.

U.S. Department of Justice (DOJ)

The U.S. Department of Justice prosecutes both civil and criminal violations of the False Claims Act. It also handles whistleblower cases under the False Claims Act’s qui tam provisions—which allow employees, former employees, citizen journalists, and other individuals to file Medicaid fraud lawsuits on behalf of the federal government.

How Whistleblowers Can Help

With all of this in mind, if you have (or believe you may have) information about Medicaid fraud, how can you help? The federal government relies on Medicaid whistleblowers to:

• Document Medicaid Fraud (or Suspected Medicaid Fraud) – If you are aware of fraudulent billing practices (or if you suspect Medicaid fraud), you should take detailed notes and keep any documents you have in your possession. You should talk to an attorney before taking additional documents from your employer.
• Expose Medicaid Fraud (or Suspected Medicaid Fraud) – As discussed above, exposing Medicaid fraud typically involves filing a qui tam lawsuit under the False Claims Act. Our attorneys can determine if you are eligible to file and then take appropriate action on your behalf.
• Provide Additional Assistance During the Government’s Investigation – While not legally required, the government generally expects whistleblowers to provide additional assistance during its Medicaid fraud investigation. Our attorneys can help here as well.

At Oberheiden P.C., our attorneys work with the government on behalf of Medicaid fraud whistleblowers nationwide. Several of our attorneys have prior DOJ experience, and we are intimately familiar with the False Claims Act’s qui tam provisions. If you think you may be able to serve as a whistleblower, our attorneys can explain everything you need to know, and we will represent you at no out-of-pocket cost.

FAQs: Identifying and Exposing Medicaid Fraud in Health Care

Speak with an Experienced Medicaid Whistleblower Attorney in Strict Confidence

If you would like more information about exposing Medicaid fraud to the government, we strongly encourage you to get in touch. To speak with an experienced Medicaid whistleblower attorney in strict confidence as soon as possible, call 888-680-1745 or request a free consultation online today.

Further Information About Our Medicaid Whistleblower Lawyer Services

• Medicaid Whistleblower Lawyer
• Medicaid Whistleblower Process
• Medicaid Fraud Whistleblower Rewards
• Do I Need to Hire a Medicaid Whistleblower Attorney?
• Who Can Serve As a Medicaid Whistleblower?