Medicaid fraud is a growing problem as Medicaid is further expanded to other income levels. Medicaid fraud is even a problem here in Suffolk County and there are investigators looking for at providers and beneficiaries for evidence of fraud.
What Is Medicaid Fraud?
Medicaid is a federal and state partnership to provide medical care to the low-income adults, children, and families. It provides medical benefits on a cost-free basis so that those without economic means can afford health care. It’s one of the largest assistance programs and has seen extensive growth over the last few years due to its expansion under the Affordable Care Act.
Medicaid fraud can be committed by beneficiaries or providers. Beneficiaries commit fraud by deceptively receiving benefits. They might lie about their household income or how many dependents they have. They also commit fraud when they sell medicines that they obtain through Medicaid or receive kickbacks from providers for care received. The amount of money lost from this fraud is estimated at $8 billion per year.
The biggest Medicaid fraud problem is provider fraud. Providers commit fraud by submitting bogus claims to Medicaid. Here is a quick rundown of common fraud schemes by providers.
* Billing Upcode: They will enter codes for higher cost procedures on their billing forms in order.
* Unneeded Procedures: Providers will perform unnecessary procedures or tests on patients to increase their billings.
* Ghost Billings: They will continue submitting billings for patients who have died or who are no longer under their care.
* Rewarding for Referrals: They give rewards, or kickbacks, to patients for referrals or otherwise give cash to patients.
Penalties for Medicaid Fraud
Medicaid fraud carries very stiff penalties for beneficiaries and providers. Penalties can be meted out by state and federal authorities, depending on the severity of the fraud and the amount fraudulently obtained.
Provider fraud represents the biggest fraud concern and therefore has some of the toughest penalties. Providers who defraud the Medicaid program can expect that they will be subject to an increasing level of penalties. These are dependent on the severity of the fraud and the amount defrauded.
1. Restitution of wrongly billed services
2. Temporary Disqualification from program
3. Permanent Disqualification from program
4. Loss of Medical License
5. Criminal Prosecution of up to a Class B felony that carries jail time and fines
In 2016, a Suffolk County medical supply business owner pleaded guilty to Medicaid fraud. She submitted more than $2 million in bogus claims for medical supplies. Her conviction carried a sentence of up to 6 years in prison.
Beneficiaries who commit Medicaid fraud are subject to an array of penalties as well, depending on how severe the fraud was. Sometimes they are just asked to pay back the wrongfully gained benefits and be temporarily suspended from the program. Other times they are permanently barred from the program and are required to make restitution. On rarer occasions, they are sentenced to jail and have to pay fines.
How is Medicaid Fraud Investigated?
Beneficiaries are audited from time to time by the State of New York using both IRS, Social Security, and private databases to ensure that the income reported on the forms match their truthful levels. When information doesn’t match, a fraud investigation can be started.
Beneficiaries are usually called into the office to clarify information on the application. At this stage, the investigator is collecting information to see if fraud occurred and the penalties that should be applied. If the fraud is severe, the investigator may refer the case to the Attorney General for prosecution. At any stage, the beneficiary can ask for a hearing on any determination given.
Since more people than ever are on Medicaid, there is some evidence that provider fraud is on the increase as well. To combat this, investigative resources have become more focused on this type of fraud. An investigation is usually opened one of two ways. Either a tip is called into the fraud hotline or a routine examination of billings shows some kind of irregularity.
Once an investigation is open, the investigator, or team of investigators, will begin collecting information. They may not immediately contact the provider and notify them of the investigation. Depending on the severity of the fraud, they may issue a determination and penalties that will be applied. The medical provider can ask for a hearing to dispute the evidence collected and the determinations made. In cases of severe fraud, the case may be immediately referred to the Attorney General for prosecution.
Medicaid Fraud Defenses
The best defense for a provider in Suffolk County suspected of fraud is to immediately contact a Suffolk County Medicaid attorney who has experience providing a solid legal defense against these type of charges. An attorney will protect your rights and ensure that the investigation is conducted correctly. Investigators are not perfect and an attorney can ensure that the rules are correctly followed in the investigation.
Calling into question any tips provided that formed the basis for the investigation is important. This extends to any irregularities.In order for any actions to be considered fraud, there needs to be an intentional deception involved of some sort. Any attorney can defend a case by showing that there are mitigating circumstances or other findings that show that there was no intentional deception and that fraud didn’t occur. This severity reduction is one defense method that can turn a criminal fraud case into a simple restitution case.
Medicaid usage is increasing and it’s no wonder that Medicaid fraud investigations will continue to increase. Whenever a fraud investigation is opened, it’s important to contact a local Suffolk County Medicaid fraud attorney who can help ensure that rights are protected.