Before getting into the crimes associated with Medicaid, it may help to briefly explain Medicaid itself. Only those claiming Medicaid benefits or those familiar with other recipients of the program might really understand what it entails. We know it provides for medical care for those unable to afford commercial health insurance, but where does the funding come from? It’s actually a cost-sharing initiative in which the federal government contributes to state programs. As such, healthcare providers are answerable to both the federal and state governments.
What Constitutes Medicaid Fraud?
There isn’t just one type of criminal fraud associated with Medicaid, according to the Office of Inspector General. Healthcare providers from hospitals to physicians have been known to commit various types of Medicaid fraud. To begin with healthcare providers, doctors have been known to bill Medicaid for X-rays, blood tests, and other diagnostic tests that were never actually performed. A more common practice, however, is to submit patients to those tests unnecessarily to pad the bill and therefore boost their income. Some doctors may also prescribe a generic drug to a patient, while billing Medicaid for the name brand drug.
Another practice common among physicians is to provide a disabled patient with a motorized scooter, but telling Medicaid it was actually an electric wheelchair. The latter can be as much as triple the cost of a scooter. Inappropriate billing such as this may be a common practice, but it’s also illegal.
Additionally, healthcare providers may bill Medicaid programs for care not given, either by billing deceased or fictitious patients or by billing patients no longer under the facility’s care. Along similar lines, a healthcare facility may compel patients to be transported unnecessarily by ambulance, which is a costly expense for Medicaid and patients.
A practice seen more commonly in the news of late is the practice of asking vendors for kickbacks. In exchange for referring patients to a specific vendor (such as particular pharmaceutical companies), the physician receives a kickback in the form of a cash bonus, aid vacation, or free merchandise.
Medicaid Fraud Control Units Seek To Stop Abuses
The Medical Fraud Control Unit in each state investigates cases that involve the abuses mentioned above, as well as other allegations of misconduct. Additionally, cases of physical abuse and criminal neglect of patients in Medicaid licensed healthcare facilities are also investigated. These agencies also investigate fraud committed by individuals within the Medicaid organization.
If a prosecutor can prove Medicaid fraud was intentional, a conviction carries very stiff penalties, reports AAPS Online. In cases where an individual healthcare provider filed false information, which covers many of the aforementioned issues, he can receive a prison term of up to five years and a fine of up to $250,000. A corporation would be subject to a fine of up to $500,000 for the same type of felony conviction.
There are also misdemeanor Medicaid fraud charges that carry slightly less severe consequences. An individual can be fined as much as $100,000, while a corporation would receive a maximum fine of $200,000.
Additionally, healthcare providers can be charged with violating The False Claims Act. Under this act, the state must be able to prove that the physician or institution knowingly submitted false statements and that the healthcare provider knew the information to be false at the time it was submitted. A third component of this law requires that the false information was intended to influence the actions of the agency to which it was submitted.
A conviction for violating The False Claims Act also carries a five year imprisonment term. The fine assigned to a convicted defendant can be as much as $10,000.
Whether a felony or misdemeanor, these penalties are per occurrence. In a case where a doctor routinely falsifies his patient’s records, for example, and submits false claims for 10 patients, he might be facing felony charges that will result in a fine up to $2,500,000. If the doctor in this example is also charged with violating the False Claims Act, he might also be fined an additional $100,000.
If you suspect a healthcare provider of falsifying documents to defraud the government, contact your area Medicaid Fraud Control Unit. Abuse can take many forms from theft and larceny to physical abuse and the negligence of patients. In many states, it is also a crime to fail or neglect to report such abuses. Typically a Class A misdemeanor, failure to report abuse to the government can result in a penalty of up to one year of imprisonment.
Only by eliminating misconduct can we reduce the costs of healthcare on all of us. Even state and federally funded programs are financed by the people through taxes, so ignoring instances of misconduct ultimately affects everyone’s financial standing. A dishonest healthcare provider isn’t just stealing from the government. They’re also lining their pockets with your tax money. Stand up for Medicaid, for patients, and for yourself by putting a stop to fraud.
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