Medicaid is a vital part of the United States healthcare system, and many people rely on it for the care they need. Many recipients often do not have a choice when it comes to their Medicaid provider, which can make it difficult to address discrepancies in costs and care. Still, Medicaid fraud is a serious issue that costs taxpayers and recipients a lot of money every year, not to mention harm to public health. 

The tricky part is that while fraud is usually the provider’s role, recipients can also commit it. Either way, both the state and the federal have made it a top priority to crack down on Medicaid fraud. Many agencies, task forces, and whistleblower incentives exist to uncover such fraud. 

If you are a provider or a recipient dealing with Medicaid fraud, you should have a capable lawyer ready to face it. At Norman Spencer Law Group, our lawyers are very familiar with handling  Medicaid fraud cases. 

Types of Medicaid Fraud

At its most basic definition, Medicaid fraud is when someone deliberately falsifies or misrepresents the truth for unwarranted benefit. Several types of fraud that can happen from the provider includes:

  • Billing for services not provided 
  • Billing for unneeded items or services
  • Unbundling
  • Upcoding
  • Drug Diversion
  • Kickbacks
  • Billing for ineligible beneficiaries 
  • Performing tests or giving medications to the wrong person

There are also examples of patient/recipient fraud, which include:

  • Filing claims for unreceived items
  • Altering receipts from a healthcare provider
  • Reselling medicine or equipment acquired through Medicaid 
  • Using false information to obtain Medicaid services 
  • Using the same prescription multiple times with different doctors
  • Using another person’s ID to get Medicaid services/coverage
  • Giving away your ID so someone else can use it for Medicaid services/coverage

Finally, the insurance company in charge of an organization’s or patient’s claims can also be involved in Medicaid fraud. Medicaid insurance fraud includes:

  • Denying a valid claim
  • Undervaluing the money owed to a Medicaid provider
  • Misrepresenting healthcare benefits to beneficiaries 
  • Padding costs within insurance claims

These examples are common forms of Medicaid fraud, and they can bring about regulatory oversight or punishment. Punishments can include jail sentences of at least five years, sizable fines, probation/ expulsion from Medicaid programs, restitution, and civil penalties up to $20,000. One of the heavier penalties is paying out treble damages, which multiplies the amount a provider or insurer took from the government by up to three times in damage costs.

Medicaid Fraud Investigations

While there are many types of Medicaid fraud, many different agencies are investigating. Chief among them is the Medicaid Fraud Control Units (MFCUs). These agencies are located in every state, and most of them operate under their respective State Attorney General offices. MFCUs investigate Medicaid fraud, misuse or misappropriation of funds, patient abuse, and neglect. 

The Office of Inspector General (OIG) and the Department of Health and Human Services (HHS) also investigate Medicaid fraud. Not only can they engage in independent reviews of a provider, but they can also form task forces with the FBI and local law enforcement. Additionally, the OIG and HHS review the performance of MFCUs. 

These groups are far-reaching, but they do not cover everything. Patient fraud, for example, falls out of these groups’ jurisdiction. The Department of Social Services tends to handle those cases,

The federal government offers employees at institutions financial rewards and protection if they become whistleblowers to report fraud. They also protect whistleblowers if their employers retaliate against them. Whistleblowers receive a portion of the recovered money from fraud cases as a reward if the investigation is successful.

If You Are Facing Medicaid Allegations

When faced with accusations of Medicaid fraud, whether you are a provider, an insurer, or a recipient, your first order of business should be to contact a law firm that is well-versed in Medicaid fraud defense. A lawyer can help deal with some of the most challenging aspects of such an allegation and the procedures.

Since Medicaid fraud defense is an involved process, a lawyer can significantly streamline it. A healthcare defense attorney can help you go through relevant claims for your case, keep track of important correspondence with your employees or government agencies, gather necessary documents, and prep your employees when dealing with government representatives. A reliable healthcare defense attorney is indispensable if you must go to court.

At Norman Spencer Law Group, we know the healthcare field inside and out. Our attorneys have experience with any cases that can come up in healthcare, including Medicaid fraud defense. If you are dealing with a fraud case, do not hesitate to give us a call. We can provide you with a free consultation over the phone, ZOOM, or even in person.