Medicaid Fraud

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.

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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 comprehensive procedure was performed. Facilities such as pharmacies commit fraud by substituting brand name drugs for generic drugs and billing Medicaid for the brand name drug.

Still other facilities receive kickbacks and file false cost reports. Kickbacks involve receiving payments or services for referral of patients to other facilities or providers where the patient will receive unnecessary services to generate additional income. False cost reports are seen in nursing home cases of fraud and involve owners filing charges for their own personal expenses. Individuals enrolled in Medicaid programs commit fraud by hiding resources, assets, and income.

They also commit fraud by denying spouses live in their households or failing to report marriage to continue receiving Medicaid benefits. Individuals with private health insurance who fail to report this insurance and continue using Medicaid benefits are committing fraud. It is an abuse of the Medicaid program when individuals who could obtain coverage on their own instead enroll in Medicaid to cover their medical expenses. Also the federal government stipulates that an individual cannot receive Medicaid in more than one state at the same time.

Often, individuals move to another state and fail to report or close their Medicaid benefits with the state in which they were residing. Some individuals want to maintain coverage in more than one state because benefits differ from state to state and some individuals will travel between neighboring states using their Medicaid benefits. This constitutes Medicaid fraud. A program to fight Medicaid fraud has cost the United States at least $102 million in auditing fees since 2008 while identifying less than $20 million in overpayments, investigators found (Wayne, 2012).

According to the National Association of Medicaid Fraud Control Units (2012), Medicaid provider fraud costs American taxpayers hundreds of millions of dollars annually and hinders the very integrity of the Medicaid program. Medicaid fraud affects recipients, providers, health care facilities, and taxpayers. Fraud increases the costs of providing benefits to Medicaid recipients. To compensate for such fraud, states must either raise taxes or decrease services in other areas. Those who most need Medicaid services may not be able to obtain benefits because resources are not available.

For patients, Medicaid fraud could mean tampering with their medical records, which could put their health at risk. People can get hurt when doctors or other providers give less or more care than needed just to make more money. Also the public is more skeptical about social service programs as more incidents of Medicaid fraud occur every day. Providers and facilities who commit Medicaid fraud can face penalties from state and federal governments. Federal or state authorities may investigate allegations of fraud depending on where the fraud was reported, the laws broken, and the amount of money involved.

The strictness of penalties levied by state governments varies from state to state. Federal laws such as The False Claims Act, Anti-Kickback Statute, and Social Security Act are laws that address fraud and abuse. Title XI of the Social Security Act contains Medicaid program-related anti-fraud provisions, which impose civil penalties, criminal penalties, and exclusions from federal health care programs on persons who engage in certain types of misconduct (Staman, 2010).

Under federal regulations, providers convicted of fraud are excluded for a minimum of five years from receiving funds from any federally funded health care program, either as a health care provider or employee (National Association of Medicaid Fraud Control Units, 2012). The False Claims Act imposes penalties on anyone who knowingly submits false claims for payment through a governmental program. Penalty for conviction under this Act is a fine not exceeding $10,000 or an imprisonment of up to five years, or a combination of the two (Centers for Medicare and Medicaid, 2011).

The Anti-Kickback Statute makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program (Centers for Medicare and Medicaid, 2011). Violations of this law are punishable by up to five years in prison, criminal fines up to $25,000, administrative civil money penalties up to $50,000, and exclusion from participation in federal health care programs (Centers for Medicare and Medicaid, 2011). There are other federal laws to address fraud and abuse of government programs such as Medicaid.

These penalties are a reactive measure to control abuse of Medicaid, but proactive measurements are needed to discourage providers, individuals, and facilities from committing fraud. On October 27, 1977, President Jimmy Carter signed the legislation that provided each state with the opportunity and resources to establish a Medicaid Fraud Control Unit (MFCU) to investigate and prosecute provider fraud (National Association of Medicaid Fraud Control Units, 2012). The MFCU investigates Medicaid provider fraud and misuse of Medicaid recipients’ funds.

The jurisdiction of the Medicaid Fraud Control Units is limited to investigating and prosecuting Medicaid provider fraud, MFCU’s do not investigate recipient fraud. States must also take initiatives to curtail fraud. Many states are looking to use new technology as a means to prevent fraud. One such technology is biometrics. Biometric technology compares a user’s feature such as a fingerprint. This technology has the potential to prevent recipient fraud by eliminating card sharing as well as preventing provider fraud by reducing phantom billing and other forms of fraud.

New York, for example, has integrated targeted data mining and risk analysis into its fraud-fighting tool box. In Texas, a few simple process changes and new pattern analysis and recognition efforts moved the state closer to ‘real–time analysis’ and significantly increased the amount of fraud identified (National Conference of State Legislators, 2012). States must develop continually ways to prevent Medicaid fraud and protect the resources provided for recipients. Controlling Medicaid fraud will be a continual task.

The burden falls not on just the federal government, but also state governments, facilities, providers, recipients, and citizens. States should fully commit to working with federal policymakers and agencies to improve the integrity of the Medicaid program. Clarity is needed to define federal and state government roles in maintaining integrity of the Medicaid program. Collaboration and communication between Medicaid and Medicare is needed to reduce fraud. States should evaluate the utility of existing tools used to fight Medicaid fraud. Incentives for providers, recipients, and citizens to report suspected fraud must be made available.

Abuse of Medicaid affects everyone and costs will continue to rise if measures are not taken to use better the resources available in the Medicaid program. References National Association of Medicaid Fraud Control Units. (2012). What is Medicaid Fraud?. Retrieved from http://www. namfcu. net/about-us/what-is-medicaid-fraud Mackelvie, C. F. (2004). "The impact of fraud and abuse regulations - Medicare and Medicaid fraud and abuse statutes. Retrieved from http://findarticles. com/p/articles/mi_m3257/is_n10_v46/ai_13413481/pg_6/? tag=content;col1 Wayne, A. (2012). Medicaid Fraud Audits Cost Five Times Amount U. S. Found. Retrieved from

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