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Information you need to know to avoid Medicaid fraud

| Jul 4, 2021 | Blog, Medicare & Medicaid |

As a health care provider accepting Medicaid, there are times you may have received an overpayment. It is a common issue that you can remedy with a refund.

However, missing an overpayment and not correcting the mistake may lead to the government subjecting you to a fraud investigation. What are common types of Medicaid fraud, and what happens if there is an investigation?

Types of Medicaid fraud

Most Medicaid fraud happens when a provider incorrectly or fraudulently bills or codes services. Types of fraud that concerns billing include:

  • Billing for services not performed
  • Billing for a service that not covered
  • Billing duplicate times for one service
  • Billing for a more costly service

Other types of fraud are:

  • Accepting kickbacks
  • Falsifying a diagnosis
  • Ordering inappropriate tests
  • Prescribing medications not medically necessary

To protect yourself from fraud claims, maintain accurate and complete medical records of the services you provide to your clients.

The investigative process

A fraud inquiry starts because of:

  • An individual witnesses the fraud and notifies CMS
  • A patient reports a billing issue and files a complaint
  • A person notices a pattern of abuse

Texas’ Office of the Attorney General and the Office of Inspector General coordinate to look into suspected Medicaid fraud. They share information about providers to help in the investigative process.

At the onset of the investigation, you will receive a letter from the Centers for Medicare and Medicaid Services. A team may request access to your billing and coding records and ask to interview you and your employees.

Many fraud investigations happen because of honest mistakes, but those errors can be costly to you, your employees and your patients. Protect yourself and your business by understanding how Medicaid fraud occurs.

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