What Is Medicaid?
Medicaid is a government program for those who aren’t able to afford private health insurance. There are requirements that need to be met after an application is completed. The applicant can’t make over a certain amount of money each year or month depending on how the state calculates the required limits. Medicaid is used for routine doctor’s visits and specialty care visits, but there is a co-payment at times of a minimal amount. Children are often approved for Medicaid until they are 18 if the parent applies.
As with other programs that are based on income amounts, there are people who will try to commit Medicaid fraud. Some of those who commit fraud are doctors and pharmacists who are trying to get more money from the government. There are several ways to commit Medicaid fraud, but those who are caught will likely face harsh penalties.
One of the ways that people commit fraud is by lying on the Medicaid application. Since the approval of the benefit is based on the income that the applicant receives each month, some people will claim that they don’t have income when they really do or claim that there are fewer people in the home than there are so that all incomes are accounted for when the application is processed. However, Medicaid offices can easily track information that relates to income by contacting employees to find out exactly how much money is made or by looking at past tax returns that have been filed.
Fraud is committed by billing for services that aren’t provided. This is often done by doctors and pharmacists. These groups of people will often work together in order to make as much money off the government as possible through Medicaid. A similar act is billing for services that aren’t medically necessary. The doctor’s office will receive payment for the services that it turns in, so if the doctor claims that something was performed, even when it wasn’t, then the office will still receive payment.
There are a few acts that take place with the computer system in regards to committing fraud. Codes can be changed, offices can upcode or use more codes than necessary or double-bill for services. When double billing occurs, there are usually two offices working together so that both can get paid. One doctor will file for services and claim that a specialty doctor needs to be seen without the patient going to the specialty care office. Doctors can report false prices for services that are provided and false cost reports. Medicaid offices usually won’t know that the prices are false unless they investigate or someone makes a report about the issue.
Some offices will accept kickbacks from insurance companies and other businesses if they falsify information in order to get more money from Medicaid. Medical documents must be maintained in a proper manner. If they aren’t, then some services can get confused with others. There are doctors who do this on purpose to confuse the Medicaid office so that they can get more money. Pharmacists will commit prescription fraud by declaring that someone needs a certain medication, charging for that medication through the system and only giving the patient a generic medicine. Doctors will create self-referrals so that they can get more money. Doctors will visit each other without getting any kind of treatment just to file a claim. Sometimes, doctors will file claims for patients who don’t even exist.
Individuals who commit Medicaid fraud are a little different. They realize that they are committing the fraud, but they don’t care so that they can get some kind of healthcare. Doctors who commit Medicaid fraud understand what they are doing and commit fraud for the money. Those who know about the fraud are required to report it as soon as they know that it’s taking place. If they don’t make a report, then they can be held accountable as well.
Depending on the circumstances, Medicaid fraud is punishable by spending time in jail. According to Chapman Law Group, Medicaid fraud is considered a felony no matter how much money is involved. Many states have a cutoff for the difference between a misdemeanor charge and a felony. Most people who are convicted of the fraud will spend a few months in jail up to a few years depending on the amount involved. Probation is an option, usually for those who are convicted of a misdemeanor.
There are a few defenses that offices like the Spodek Law Group can use in court. One is that there was no knowledge of the fraud taking place, which is commonly used if office personnel is charged with the doctor. Another defense is that the applicant unintentionally left off information and didn’t intend to not report income.
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