If you know of Medicaid/Medicare fraud in Texas call us in total confidence today—we will take action!
What can you do to stay out of trouble with the law when you work for a clinic, hospital, nursing home, or hospice that commits Medicaid Fraud? Find out how reporting fraud may lead you to a cash payment!
Some medical institutions profit from undeserved funds due to Medicaid and Medicare Fraud. People who commit Medicaid and Medicare Fraud waste countless tax dollars. As a result, important government programs are deprived of needed funding. A Whistle Blower is one that blows the whistle on Medicaid and Medicare Fraud by reporting the fraud.
What is Medicaid and Medicare?
- Medicaid is a federal/state cost-sharing program that provides health care to people who are unable to pay for such care.
Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure (called “End-Stage Renal Disease”).
What is Medicaid/Medicare provider fraud?
- Medicaid providers include doctors, hospitals, nursing homes, pharmacies, clinics, counselors, personal care/homemaker chore companies, and any other individual or company that is paid by the Medicaid program. If a provider intentionally misrepresents the services rendered, and therefore increases their reimbursement from Texas Medicaid, provider fraud has occurred.
Psychiatric Fraud
Texas foster children and Texas children of low income families are often victims of Medicaid fraud perpetrated by psychiatrists. Unnecessary treatments involving highly toxic medications are prescribed without the standard of care and due diligence to discover whether the manifestations that the psychiatrist relies upon in his/her diagnosis stems from other physical problems, nutritional deficiencies, or a language barrier.
Example: Child is diagnosed with a learning disorder after a five-minute diagnosis by a psychiatrist. The child is prescribed an attention deficit drug and Medicaid pays the bill. However, a proper medical examination would have revealed that the child is suffering from undiagnosed diabetes which can affect behavior, and the child’s inadequate skills in understanding the English language also affect his/her ability to learn.
Off label Drugging
Medicaid Fraud and Medicare fraud involving prescribing of anti-depressants and psychiatric drugs can be a harsh abuse of government funds. Reimbursement under Medicaid is available in most instances for covered outpatient drugs that are FDA-approved for a particular use. Covered outpatient drugs do not include drugs that are used for a medical indications which are not a medically accepted. A medically accepted indication use come under the Federal Food Drug and Cosmetic Act or which is included in American Hospital Formulary Service Drug Information, United States Pharmacopeia-Drug Information, the DRUGDEX Information System, and American Medical Association Drug Evaluations, and the peer-reviewed medical literature.
Example: An off label drug has been approved for treating depression, but is prescribed for treating elderly persons with signs of Alzheimer’s and certain forms of dementia.
Example: An off label drug has been approved for treating schizophrenia, but is prescribed to a person with mild retardation and who is exhibiting symptoms of a learning disorder.
How can I spot Medicaid fraud?
- Many of the cases prosecuted start with information from private citizens. If a provider suggests treatment or services that you do not realistically believe are necessary, be cautious of the recommendation.
- If you are a recipient, be wary of “free” tests, services, or medical products offered in exchange for your Medicaid information.
- If you are the legal guardian of a Medicaid recipient who is in a nursing home or other health care facility, check the recipient’s personal funds account regularly.
- If you are visiting in a nursing home or other health care facility, pay attention to the patient’s appearance and the appearance of the room for any indication of abuse or neglect.
Examples of Medicaid Fraud are the following:
- Billing for Services Not Performed: A provider tries to bill Medicaid for a treatment, or procedure, or service, which was not actually performed – such as mental health services that were never given, billing for blood tests when no samples were drawn, billing for a physical therapy session when one was not done; billing for home health care hours when they were not provided, etc.
- Double Billing: A provider attempts to bill Medicaid and either a private insurance company or the patient for the same treatment. Or two providers try to get paid for services rendered to the same patient for the same procedure on the same date.
- Substitution of Generic Drugs: A pharmacy might try to bill an insurance carrier or the patient for the cost of a name brand prescription when in fact a generic substitute was supplied at a substantially lower cost.
- Unnecessary Services: A provider might misrepresent the diagnosis and symptoms on a patient’s records and billing invoices to obtain payment for unnecessary lab tests.
- Kickbacks: A provider may conspire with another provider to give a kickback, either money, gifts, or products, when they receive a referral from the other provider or use the other providers products or services. For example, if a laboratory company that does blood testing offers to pay a doctor $20 for every patient that doctor sends to that laboratory, then both the laboratory company and the doctor have engaged in an illegal kickback scheme. Paying the doctor for referral of business encourages unnecessary testing and therefore unnecessary billing.
- Cost Reports: A provider may include inappropriate expenses in claims made to Medicaid. These expenses often include the costs of items for personal consumption and use. For example, nursing home providers submit annual reports to the Medicaid program explaining how much it costs to take care of a nursing home resident. Only those costs that are related for resident care are allowable. Some providers fraudulently include personal costs, such as the remodeling of their own home, in the nursing home cost report and falsely describe it as work done at the nursing facility. The provider then submits a bill for an inflated rate for resident care based upon this false information.
- Upcoding: When a provider exaggerates the level of service performed then that is referred to as upcoding. For instance, if a patient sees a doctor for ten minutes on a simple matter such as a cold and the doctor then submits a bill for an hour-long complex visit, that doctor has upcoded. It is improper for a doctor to falsely “upcode” the level of service from a short, simple visit to one of greater length designed for analyzing a much more complicated medical matter, when that is not what happened.
- Unbundling: This occurs when a provider breaks one medical event into its component parts. For example, bills are submitted individually to medicaid or medicare when they are required to be billed together at a reduced cost.
- Identity Theft/Use of Provider Numbers: Identity theft occurs when criminals steal information from providers and patients and use it to bill the Medicaid program for health care services or goods that were not provided. Some beneficiaries may sell their Medicaid number to others who submit bills for health goods and services that were not provided.
Additional Important Information:
- The Texas Medicaid Fraud Prevention Act (TMFPA), chapter 36 of the Texas Human Resources Code, permits private citizens to file lawsuits on behalf of the state against those who violate the TMFPA.
- These private citizens who identify and pursue fraudulent activity committed against the Medicaid program may receive a portion of the recovery.
- Recovery for Medicaid fraud violations include a fine of between $5,000 and $15,000 per violation against a senior citizen, disabled person or minor; and a fine of $5,000 to $10,000 for other groups of people.
