Medicaid Fraud

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Medicaid Fraud
HCS/545
July 9, 2012

Medicaid fraud comes in many forms. A provider who bills Medicaid for services that he or she does not provide is committing fraud. Overstating the level of care provided to patients and altering patient records to conceal the deception is fraud. Recipients also commit fraud by failing to report or misrepresenting income, household members, residence, or private health insurance. Facilities have also been known to commit Medicaid fraud through false billing. The Medicare and Medicaid fraud and abuse statute provides that an individual who knowingly and willfully offers, pays, solicits, or receives any remuneration in exchange for referring an individual for the furnishing of any item or service (or for the purchasing, leasing, ordering, or recommending of any good, facility, item, or service) paid for in whole or in part by Medicare or a state health care program (i.e., Medicaid) shall be guilty of a felony; this is known as the “anti-kickback” statute (Mackelvie, 2004). Medicaid fraud affects taxpayers, recipients, and health care organizations. Measures to reduce Medicaid fraud are necessary.

Individuals, facilities, and providers commit Medicaid fraud in several ways. One of the most common ways providers commit fraud is billing for services never provided. For instance, a physician may bill Medicaid for x-rays or lab work that the patient never received. Another way is double billing. Double billing occurs when both Medicaid and a private health insurance are billed for the same services. Medicaid is secondary health insurance to private health insurance and should be billed only for the charges that the primary health insurance does not pay. A third way providers commit Medicaid fraud is billing for phantom visits; charging Medicaid for seeing a patient who has not been seen. Providers have committed Medicaid fraud by billing for unnecessary tests and billing for more expensive procedures when a limited or less...
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