Home Health Care Fraud Medicaid

Medicaid Fraud

Medicaid, a state-administered health care program funded jointly by states and the federal government, is also compromised by health care error, fraud and abuse. The health-related expenses of beneficiaries eligible for Medicaid are paid by Medicaid alone or by both Medicare and Medicaid, rather than by Medicare and the beneficiary. The Medicaid program is vulnerable for the same reasons that Medicare is, with state and federal government paying the bill for the wasteful or fraudulent co-pays, deductibles or premiums, not the beneficiary. Beneficiaries involved in Medicaid may still pay, however -- with their health. Medicaid fraud can lead to inappropriate, delayed or denied health care services. Because Medicaid in particular serves society's most economically and/or physically vulnerable citizens, its beneficiaries can be seen as an easy mark by unscrupulous persons.  Their vulnerability also creates barriers to detecting and reporting errors, fraud and abuse when they occur.

The problems are not going unnoticed. SMP projects target their outreach efforts to Medicaid beneificiaries in their state, partnering with their state ombudsman programs to help those who live in nursing homes or other facililites. State Medicaid Fraud Control Units (MFCUs) and State Program Integrity Units investigate and prosecute health care providers and also look into complaints of abuse and neglect. The National Association of Medicaid Fraud Control Units helps members deter health care provider frauds, recover program dollars, punish corrupt practitioners and prosecute those who abuse or neglect nursing home residents. The federal government's HEAT initiative is designed to stop Medicare and Medicaid fraud. 

Though states are allowed to develop their own Medicaid coverage guidelines, these guidelines must be within certain limits dictated by the Centers for Medicare & Medicaid Services (CMS), the organization that administers Medicare and Medicaid. Click here for a brief overview of Medicaid. The CMS website covers everything from enrollment and coverage to how to prevent, detect and report fraud. 

CMS warns people to avoid common rip off and fraud schemes.

Protect Yourself

• Treat your Medicare, Medicaid and Social Security numbers like a credit card number. Never give these numbers to a stranger.
• Remember, Medicare and Medicaid don’t call or visit to sell you anything.
• Don’t carry your Medicare or Medicaid card unless you will need it. Only take it to doctor’s appointments, visits to your hospital or clinic or trips to the pharmacy.
• Record doctor visits, tests and procedures in your personal health care journal or calendar. If you are a caregiver, keep these records for your loved one.
• Save Medicare Summary Notices and Part D Explanation of Benefits. Shred the documents when they are no longer useful.
• Rely on your doctor's advice first. Avoid offers of “free” medical tests or supplies in exchange for a “peek” at your Medicare or Medicaid card.
• Beware of advertising that promises Medicare or Medicaid will pay for certain care or devices.
• Never sign a blank form. Always read and keep a copy of any document or agreement you sign.
• Ask to see a copy of your care plan to verify you are receiving all of the services that are being paid for on your behalf.
• If you rent medical equipment, such as a walker, return the item to the medical equipment dealer when finished. Always get a dated receipt for the return.
• Beware of offers of TENS units (battery-powered units that send electrical impulses to reduce pain), nebulizers (breathing machines), non-invasive blood flow studies, “free” cholesterol checks and promises of “stroke prevention.”  Rely on your own doctor’s advice to prescribe appropriate treatment for you.

For More Information

• GAO Report -- Medicaid: Fraud and Abuse Related to Controlled Substances Identified in Selected States
• Kaiser Website with Health Policy Analyses. A leader in health policy and communications, the Kaiser Family Foundation is a nonprofit, private operating foundation focusing on the major health care issues facing the United States, as well as the U.S. role in global health policy.
• Medicaid Fraud: Who You Gonna Call?
• Medicaid Tip Sheet
• State Attorney General: Contact your state attorney general’s office to report scams. The attorneys general serve as counselors to state government agencies and legislatures and as representatives of the public interest. When you click the link, scroll to the bottom of the page to find the map and click on your state.