Medicaid Fraud

Doctors, hospitals, physical therapy clinics, home healthcare agencies, medical transportation companies and other medical care providers sometimes take advantage of our tax dollars by making false claims to the Medicaid Program.

Some common Medicaid fraud schemes include:

• Billing Fraud. Billing fraud occurs when a healthcare provider bills for services he or she never performed, upcodes or bills for more services or those of a higher level than that which was actually performed, or when a provider exaggerates the amount of time spent with a patient.
• Provider Licensing and Credentialing Fraud. Providers billing Medicaid need to comply with State and Federal licensing requirements. In addition, for a provider to properly bill a Medicaid managed care insurer, he or she must be credentialed with that insurer.
• Medical Necessity Fraud. Providers who bill for tests or medical procedures which are not medically necessary are committing Medicaid fraud.
• Stark Law or Anti-Kickback Statute violations. It is illegal to pay for Medicaid patient referrals. It is also illegal to pay improper compensation to physicians in exchange for referring, ordering, or performing certain healthcare services or items covered by Medicaid.

Other common types of Medicaid Fraud include:

• Home Attendant, Home Health or Personal Care Fraud. Home healthcare agencies sometimes bill aides for longer hours than necessary or more hours than medically indicated. Other times documents are forged so that aide services are granted to patients who don't medically or legally qualify for such assistance.
• Pharmacy and Pharmaceutical Drug Fraud. Pharmacies may commit Medicaid fraud by billing Medicaid for a brand-name drug while actually supplying the cheaper generic equivalent. Pharmaceutical drug fraud often occurs when a drug manufacturer promotes a drug for an off-label or non-FDA approved use.
• Behaviorial or Mental Health Fraud. Mental health fraud often occurs when, for example, therapy sessions are billed for 45 minutes when the patient was only seen for a 15 minute medication management session. Billing for interns or unlicensed therapists at the rate of licensed therapists may also be Medicaid fraud.
• Transportation and Ambulance Fraud. Medical transportation providers commit Medicaid fraud by submitting bills for transportation which never happened. In addition, Medicaid rules prohibit Medicaid transportation providers from sub-contracting out their services and allowing the sub-contractor to bill under the name of the Medicaid approved provider.

If you have information about a doctor, hospital, clinic or other healthcare provider committing Medicaid Fraud, you may be able to help the government recover funds and receive up to 30% of the recovery, by becoming a whistleblower.

Please contact us only if you have evidence that a Medicaid Provider is committing fraud against the government.