Medicaid Recipient Fraud Investigation Process


Cases Of Medicaid Provider Fraud

New York Medicaid Fraud Lawyer Explains Fraud Investigation Process

As stated above in the Cases of Medicaid Recipient Fraud, provider fraud also comes in several different flavors. And again, is why both users and suppliers must work together to identify any fraudulent activity perpetrated by Medicaid suppliers.

Ways to assist the Office of Medicaid Management in identifying fraudulent activity include keeping records on the following items:

  • When you received service from a Medicaid professional.
  • Where the service took place.
  • Who the professional was who provided care to you.
  • Which services were given during the visit.
  • Any additional services ordered by the provider.

Any services billed that werent actually provided are considered fraud and need to be reported.

Examples of Medicaid supplier fraud include:

Hire Nyc Medicaid Fraud Attorney

An experienced lawyer will know what needs to be done in a Medicaid fraud allegation case. If a case cant be defended in court, a knowledgeable attorney will know how to reduce a persons criminal exposure. A lawyer will know how to assemble all of the important information to get their client the best possible outcome. They will know how to work with a specific judge or prosecutor. Most individuals who are prosecuted with Medicaid fraud in a New York court are charged with a felony. A guilty plea will result in a person having a criminal record. An attorney will know how to negotiate with a DA or Judge to have their client plead to a reduced Misdemeanor charge. In some situations, they can also negotiate a plea bargain. This will enable a person to avoid a criminal conviction, as well as a criminal record.

Submit A Hotline Complaint

OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services programs. Every report we receive is important, however, not every submission results in an investigation. Due to the high volume of complaints we receive, it is not possible to contact every complainant. However, Hotline tips are incredibly valuable, and we appreciate your efforts to help us stamp out fraud, waste, and abuse.

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How You Can Help In The Fight Against Medicaid Fraud

Medicaid Fraud ends up costing us all in the form of higher insurance premiums and taxes. Heres what you can do to help fight Medicaid Scams.

  • Review your Medicaid bill when you receive it. Did you receive each service and all supplies listed on the invoice? Are the dates correct?
  • Only give your Medicaid number to those needing it.
  • Dont lend your Medicaid card to anyone. If anyone uses it in your name they are committing a crime.
  • Never request medical services or equipment you dont need.
  • Dont sign blank forms for medical services or equipment.
  • Request and retain copies of anything you sign.
  • Only share Medicaid and your medical information with those needing it.
  • Be wary of offers for free testing and medical screenings, especially when the services are covered by Medicaid.
  • Never give out your Medicaid information to telemarketers or door-to-door salesmen pushing free medical services or equipment. Why would they need your Medicaid number?
  • Only supply those youve received medical care or services from access to your Medicaid ID card.
  • Never let medical providers bill Medicaid for services before contacting you.
  • Ignore fantastic claims made about Medicaid paying for medical care or services everyone knows they dont cover.

Is There Protection For Whistleblowers

Medicaid Fraud Investigations

State and Federal laws provide protection to employees who report fraud or abuse.

Any employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against by his or her employer for reporting fraud is entitled to relief, including job reinstatement, twice the amount of back pay, and compensation for any court costs and attorneys fees.

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How To Report Fraud

You can help protect your tax dollars by reporting suspected fraud by phone, through the Internet or by regular mail. You can do this without giving your name, but if you agree to give your name and other contact information, that helps the investigators to obtain future information.

Before you make a report, try to get as much information as possible, including:

  • the name of the person you suspect of committing fraud. This might be a person receiving medical benefits or a health care professional hospital, nursing home, or other facility that provides Medicaid services
  • the Medicaid ID number
  • the amount of money involved, and/or
  • a description of the acts that you suspect involve fraud

What Medicaid Fraud Does

Medicaid Fraud has far-reaching effects that touch almost everyone whether its the people in need of health care, honest providers of health care and then finally you the taxpayer. Every time a patient files a claim fraudulently and each time a provider bills more than they should they are taking money away from those that need it.

If you know anyone defrauding the Medicaid system you must report it immediately. Below are many forms of Medicaid abuse that you should be on the lookout for.

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Medicaid Fraud Control Unit

THE MEDICAID FRAUD CONTROL UNIT protects the State of Connecticut and its taxpayers by investigating and prosecuting fraud committed by those health care professionals and facilities who provide services paid for by Medicaid, the government health insurance program for lower income people.

The Medicaid Fraud Control Unit was established in the Office of the Chief State’s Attorney in 1978 as a result of federal legislation authorizing the states to investigate and prosecute fraud and abuse in Medicaid.

Providers can include physicians , dentists, nursing or convalescent homes, medical equipment supply companies, taxi and other transportation companies, or anyone else who bills the Connecticut Medicaid program for health care services provided to a Medicaid recipient.

Some examples of the types of fraud that can take place include:

  • Billing for treatment, medical procedures or equipment that is not actually performed or provided. Double billing, which means billing both the Medicaid program and the recipient or his or her private insurance for the same service. Billing for services that are not medically required.

  • Filling a prescription with a generic drug while billing Medicaid for the higher priced brand-name drug.

  • Kickbacks, or giving or accepting something in return for medical services.

  • “Up-coding,” which is billing Medicaid for a more expensive procedure or service than was actually performed or provided.

For more information, contact:

Receiving A Medicaid Fraud Letter What Should I Do

Multi-million dollar fraud investigation

Posted onAuthorInna FershteynComments Off on Receiving A Medicaid Fraud Letter What Should I Do?

What is Medicaid?

Medicaid is a federal and state health coverage program that provides health care to people who are unable to pay for it themselves. It is offered free of charge to those who meet the strict eligibility requirements.

The Medicaid Fraud Investigation Process

Usually, Medicaid Fraud investigations occur when the investigator suspects that you have been lying or have failed to disclose important information, whether you are a recipient of Medicaid or a provider . Medicaid Fraud Investigations often begin with a letter from a Medicaid investigator. Depending on the nature of the case, the investigator may involve one or more of the following government agencies: NYC Human Resources Administration, Office of Medicaid Provider Fraud and Abuse Investigation, Bureau of Fraud Investigation, New York State Attorney Generals Office, Medicaid Fraud Control Unit, or the Federal Bureau of Investigation.

This letter may ask to provide some proof of certain documentation and to meet with the Investigator for an interview.

Possible Consequences of Medicaid Fraud

How to Protect Yourself

If you are being investigated for Medicaid Fraud in New York, please contact NY Top Medicaid Fraud Attorney Inna Fershteyn at 333-2394 or visit our website to schedule a consultation.

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Why It Is Important

The Medicaid program is funded with both state and federal tax dollars. It is designed to pay for health care for low-income and vulnerable Floridians who need care. When people get benefits they dont deserve, or when providers are paid for services that were not supplied, it wastes your tax dollars and takes services away from those who need them.

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Reporting Medicare Fraud & Abuse

Medicare fraud and abuse can happen anywhere, and usually results in higher health care costs and taxes for everyone. Some examples include:

  • A provider that bills Medicare for services or supplies they never gave you, like charging you for a visit you never had, or a back brace you never got.
  • A provider that charges Medicare twice for a service or item that you only got once.
  • A person who steals your Medicare number or card and uses it to submit fraudulent claims in your name.
  • A company that offers you a Medicare drug plan that Medicare hasnt approved.


  • Issue of concern
  • All other pertinent information

Your report may be anonymous however, if you do not provide your name, we will not be able to call you back for more information. Your message will be kept confidential to the extent permitted by law.

You may also report fraud, waste or abuse directly to the state of Ohio by using one of the methods below:

Thank you for your assistance in keeping fraud, waste and abuse out of health care.

Please see the Program Integrity and Investigations Department Recovery Process to learn more about how CareSource manages fraud, waste and abuse recoveries.

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How Can My Medicaid Fraud Case Be Resolved

We always try to resolve Medicaid fraud investigations before they are referred to the NY District Attorneys Office. Each Medicaid fraud case boils down to money how much did the government pay for your healthcare services? The more people who receive Medicaid in a family, and the longer they are on the Medicaid program, the larger the claim.

We always begin by verifying the numbers. We need to make sure that the governments claim is correct. If not, we will press the agency to adjust it. The best-case scenario is when you are allowed to pay voluntary restitution to the City, and the investigation is terminated.

What Is Medicaid Fraud


Applications for reimbursement by Medicaid require a healthcare provider to sign a certification stating that the information contained in the application is true to the best of the providers belief. In most situations they must also certify that the procedure or product for which reimbursement is sought is medically necessary.

Medicaid fraud encompasses any situation where a healthcare provider makes a false certification in order to take money from the program they have not earned. Of course, the money is taken not only from the government, but also from the payroll taxes of every worker in America. Even worse, some kinds of Medicaid fraud endanger patients.

Medicaid Fraud Examples

Listing all the forms of fraud that greedy providers have tried would be impossible. Here are a few of the most common forms:

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Commingling Of Patient And Facility Funds

If a Medicaid-funded facility willfully deposits a residents funds into the facilitys operating account for use by the facility, the money is commingled, and the residents funds are available to pay the facilitys operating expenses rather than to benefit the resident. We investigate the commingling of funds of both Medicaid recipients and non-Medicaid residents in facilities that receive Medicaid funds.

The Investigative Process For Food Stamp Fraud

Has anyone been investigated for food stamps? The simple answer is yes. Unfortunately, some people take advantage of the Supplemental Nutrition Assistance Program meant for no- and low-income people to receive food aid.

As a result, you can receive a food stamp investigation letter that indicates you have raised some red flags within the system. Therefore, it would help to understand the investigative process for food stamp fraud to avoid getting in trouble.

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Where To Report Fraud & Abuse

Report Medicaid provider fraud or patient abuse to the Attorney Generals Medicaid Investigations Division at 881-2320. You can also report fraud or abuse online HERE.

Medicaid recipient fraud should be reported to the state Division of Medical Assistance by filing a complaint or by calling 1-800-662-7030. You can also report Medicaid recipient fraud to your local county Department of Social Services.

To report Medicare fraud, contact the Office of Inspector General, US Department of Health and Human Services, at 447-8477.

North Carolinians with information about Medicare error, fraud and abuse can also contact the North Carolina Senior Medicare Patrol Program at 408-1212.

To report private insurance fraud, contact the NC Department of Insurance or call the department at 680-7684.

To report fraud and abuse in state licensed facilities, agencies and nursing homes, contact the North Carolina Division of Health Service Regulation.

Medicaid Services Providers In New York

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This article is about what triggers Medicaid fraud investigations for NY healthcare providers and recipients. If you are a Medicaid Services Provider, here are some of the reasons you can be investigated for Medicaid fraud:

If you are a Medicaid Services Provider, here are some of the reasons you can be investigated for Medicaid fraud:

  • Bill Medicaid for services that have never been provided
  • Falsifying patients diagnoses to justify tests or other procedures that arent medically necessary
  • Misrepresenting medical procedures performed to obtain payment for non-covered services
  • Upcoding: billing for a more costly service than the one performed
  • Unbundling: billing each stage of a procedure as if it were a separate procedure
  • Filing claims for fake services and medical conditions
  • Coverage claims for non-existent illnesses
  • Filing claims for fake and staged car accidents in NY
  • Filing claims for medical care coverage for staged, fraudulent auto accident injuries
  • Illegal kickbacks
  • Billing for services provided by unlicensed personnel in violation of Medicaid rules.

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How The Medicaid Fraud Investigation Process Works

Medicaid is administered by the states, with federal funding and oversight. Medicaid Fraud Control Units are state law enforcement agencies 49 states and the District of Columbia have MFCUs, many of which are part of each states attorney generals office.

MFCUs have authority under their respective state and federal laws to investigate and prosecute violations of all applicable state laws pertaining to the provision of medical assistance and the activities of providers under state Medicaid plans. Although each state statute is slightly different, MFCU investigations always involve:

  • billing fraud involving the Medicaid program
  • abuse and neglect of residents within facilities that receive Medicaid payments and
  • misappropriation of patient funds by such health care facilities.

MFCUs investigate providers such as doctors, nurses, pharmacies, DME companies, dentists, counselors, hospitals, home health agencies and others. Patients are not investigated, except in circumstances where the patient and provider conspired or collaborated to commit Medicaid fraud.

Each MFCU employs a team of attorneys, investigators and auditors. The MFCU is not a part of the state Medicaid program, and the state program has no authority concerning these prosecutions. In fact, the MFCU has the authority to investigate and prosecute fraud within the administration of the state Medicaid program itself.

How To Submit A Tip

You dont have to give us your details when you submit a tip-off.

But it helps if you do, so we can contact you for more information if we need it.

If you want to make a report, use our tip-off form.

Or, if you cant use the webform, call our hotline:

Provider Benefits Integrity Hotline

If you have concerns relating to a health provider you can submit details to the department online by completing the tip-off form or by calling the dedicated hotline between the hours of 9am to 5pm AEST.

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Report Medicaid Fraud & Patient Abuse

NY HRA fraud E

Report Medicaid provider fraud or patient abuse to the Attorney Generals Medicaid Investigations Division at 881-2320. You can also report fraud or abuse online HERE.

Fraud by Medicaid recipients such as fraudulent eligibility or transfer of assets should be reported to the North Carolina Division of Health Benefits or to your Local County Department of Social Services.

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Possible Penalties And Punishments For Medicaid Fraud

When a person is guilty of Medicaid fraud, there are a variety of punishments they could receive. A person may have to repay Medicaid for the benefits they received and in some cases, individuals will go to prison. People have also been excluded and disqualified from receiving any Medicaid benefits in the future. Some people have even received civil judgments as well as liens on any real property they own. Its possible a persons wages could be garnished or their professional license suspended or terminated. Depending on a persons immigration status, they could even be deported.

Other State Fraud And Abuse

Unrelated to Medicaid program operations or processes, a hotline exists to provide citizens the capability to report other types of fraud, waste and abuse related to the agency of DMAS. These complaints are taken very seriously, and the information a caller provides is screened by the Office of the State Inspector General to determine if it is sufficient and significant enough to conduct an effective investigation. It is important to provide specific details in order to conduct an investigation. Examples of these types of complaints are as follows:

  • Embezzlement or other fraudulent conduct
  • Contract fraud
  • Inappropriate use of state funds
  • Falsification of documents
  • Abuse of state owned property, including personal use

OSIG administers the Hotline related to these types of allegations and will conduct and coordinate an investigation in partnership with appropriate individuals at the state agency. These types of allegations should be reported to the Office of the State Inspector General using the link listed below. You can find more information on the reporting process using the OSIG State Fraud and Abuse Hotline information sheet.

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