MEDICAID FRAUD CONTROL UNIT
The Department of Health & Human Services. (HHS)
“Medicaid Fraud Control Units have prosecuted individual providers such as physicians, dentists, and mental health professionals. In addition, the Units have also prosecuted fraud in numerous segments of the health care industry, such as hospitals, nursing homes, home health care agencies, medical transportation companies, pharmacies, durable medical equipment companies, pharmaceutical manufacturers and medical clinics.”
“A Medicaid Fraud Control Unit is…certified by the Secretary of the U.S. Department of Health and Human Services (HHS) that conducts a statewide program for the investigation and prosecution of health care providers that defraud the Medicaid program…. reviews complaints of abuse or neglect in nursing home and board and care facilities.”
The Office of Inspector General's certifies each Medicaid Fraud Control Unit.
Each Medicaid Fraud Unit consists of special investigators, auditors, and attorneys.
The Medicaid Fraud Control Unit investigates elder abuse and neglect in Medicaid-funded nursing facilities and board and care facilities that do not receive Medicaid funding.
The National Association of Medicare Fraud Units lists the following as common Medicare health care frauds by providers:
- Billing for Services Not Provided – blood tests or x-rays that were not taken or a nursing home or hospital that continues to bill for services for a resident who is no longer at the facility.
- Double Billing – a provider bills both Medicaid and a private insurance company for treatment for the same procedure on the same date.
- Billing for Phantom Visits - a provider falsely bills the Medicaid program for patient visits that never take place.
- Billing for More Hours than there are in a Day - inflating the amount of time a provider spends with patients.
- Falsifying Credentials - mispresenting the qualifications of a licensed provider, a physician who allows a non-physician to impersonate a licensed doctor who medically treats patients and prescribes drugs and then bills the Medicaid program.
- Substitution of Generic Drugs - a pharmacy bills Medicaid for the cost of a brand-name prescription when a generic substitute was supplied to the recipient at a lower cost to the pharmacy.
- Billing for Unnecessary Services or Tests - a provider falsifies the diagnosis and symptoms on recipient records and billings to obtain payments for unnecessary lab tests or equipment.
- Billing for More Expensive Procedures than Performed - a provider bills for a comprehensive procedure when only a limited one was administered or billing for expensive equipment and actually furnishing cheap substitutes.
- Kickbacks - a nursing home owner/operator requires another provider, such as a lab, ambulance company, or pharmacy, to pay the owner/operator a certain portion of the money received for rendering services to residents in the nursing home such as vacation trips, personal services, merchandise, and leased vehicles. This practice usually results in unnecessary services being performed to generate additional income to pay the kickbacks.
- False Cost Reports - A nursing home owner or operator includes personal expenses in its Medicaid claims. These expenses often include the cost of personal items.
How to Make a Medicaid Healthcare Fraud Complaint - Complaints of suspected Medicaid fraud can be reported to The Office of Inspector General's Hotline: 1-800-HHS-TIPS (1-800-447-8477)
Complaints may include the following:
- Fraud and misconduct related to Medicare and Medicaid services.
- Overall quality of care concerns such as poor hygene, sanitation and ill residents.
- Billing for unnecessary services, prescriptions, supplies, or equipment.
- Patient abuse harm and neglect.
- Telemarketing Scams and online scams in attempt to obtain personal information such as social security , medicare, medicaid numbers which may be used to make false health insurance claims.
source: oig.hhs.gov, namfcu.net
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