Crime and Safety:
Seniors > Medicaid Fraud & Elderly Abuse > What is Medicaid Fraud?
Medicaid providers include hospitals, nursing homes, ambulance companies, doctors, dentists, durable medical equipment suppliers, occupational and physical therapists, speech pathologists, orthotic appliance and prosthetic device suppliers, prescription drug dispensers, podiatric services, laboratory services, vision services, rural health clinics, non-emergency transportation brokers/companies, home health care providers and other suppliers of authorized specialty services.
Some examples of provider fraud include:
Billing for services not rendered: A provider bills Medicaid for treatments or procedures which were not actually performed, such as for X-rays and blood tests; for care allegedly given to patients who have died or who are no longer eligible; or for care allegedly given to patients who have transferred to another facility.
Billing for unnecessary services: A provider misrepresents or falsifies a patient’s diagnosis and symptoms on recipient records and billing invoices to obtain payment for unnecessary services, including transporting Medicaid patients by ambulance when it is not medically necessary.
Substitution of generic drugs: A pharmacist fills a recipient’s prescription with a generic drug or an over-the-counter drug but bills Medicaid for a higher cost name-brand drug.
Kickbacks: A Medicaid provider (such as a hospital, a transportation company or a laboratory) offers or pays kickbacks to another Medicaid provider's employees for referring a Medicaid recipient to the provider as a patient or client. A provider (such as a doctor or a hospital) requests and receives kickback payments from Medicaid providers (physical therapists, pharmacies or laboratories) in exchange for referring Medicaid business to the providers. Payments may be in the form of cash, vacation trips, or merchandise.
Double billing: A provider bills both Medicaid and the recipient (or private insurance) for the same service, or two providers bill for the same service.
Other unauthorized billings: A provider charges a Medicaid recipient for a service which is covered by and should be billed to Medicaid, or charges a recipient the difference between the provider’s usual fee and what Medicaid pays.
Activities of this nature are violations of various federal and state criminal laws. Providers who are convicted of Medicaid fraud may lose their eligibility to be providers in the Arkansas Medicaid Program and may have their professional licenses revoked.
