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VIOLENCE AGAINST THE ELDERLY
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MEDICAID FRAUD
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The State of Delaware and the
Federal Government have designated the Medicaid Fraud Control
Unit (MFCU) to investigate and prosecute illegal acts relating
to Medicaid funds. Created in 1977, the MFCU, which is housed
within the Delaware Department of Justice, was designed to
protect the Delaware residents who receive Medicaid and the
taxpayers who support the program. The MFCU has a professional
staff of prosecutors, investigators and auditors who review
allegations involving:
Medicaid Fraud: criminal fraud against the
state by healthcare providers who treat Medicaid recipients.
Patient Abuse, Neglect or Mistreatment:
criminal abuse, neglect or mistreatment of patients in
health-care residential facilities, including nursing homes and
mental health residential facilities.
Financial Exploitation: theft or misuse of
Medicaid recipients' funds by those employed in long-term care
facilities.
WHAT IS MEDICAID?
Medicaid is a federal/state cost-sharing program that provides
healthcare to people who are unable to pay for such care. The
Delaware Medicaid program is administered by the Delaware
Department of Health and Social Services.
The MFCU does not investigate fraud committed by Medicaid
recipients; such cases should be referred to the Welfare
Fraud Unit (Audit recovery management systems) within the
Department of Justice.
WHAT IS MEDICAID PROVIDER FRAUD?
Medicaid providers include doctors, dentists, hospitals, nursing
homes, clinics, pharmacies, ambulance companies and anyone else
who is paid by Medicaid for a healthcare service. Fraud by a
Medicaid provider is usually evidenced by one or more of the
following:
UPCODING - when healthcare providers bill Medicaid
for a more expensive treatment or service than the one they
actually provided to the patient; or by filling a prescription
with a generic drug, while billing for the more expensive name
brand version of the medication;
PHANTOM BILLING - billing for goods or services not
provided, such as
billing for patient visits that never took place or for blood
tests when no
samples were taken;
UNNECESSARY SERVICES - billing for unnecessary
services can
include billing for items that patients do not need at all, such
as oxygen
concentrators, hospital beds or wheelchairs;
DOUBLE BILLING - billing Medicaid twice for the
same procedure,
sometimes by submitting a bill at the beginning of the month and
a
second bill at the end for the same service;
UNBUNDLING - submitting bills for individual
procedures as if the service
were performed on different days for procedures that the doctor
performed during one day as part of one operation;
KICKBACKS - when medical suppliers, home health
agencies, etc., give
kickbacks to physicians who recommend their business to
patients; or
when corrupt doctors demand under-the-table cash payments from
patients.
Acts like those described above may violate state and federal
laws and subject
the guilty provider to imprisonment, significant fines and
exclusion from the Medicaid
program.
HOW DOES MEDICAID FRAUD AFFECT ME?
Medicaid fraud affects everyone. When providers steal from
Medicaid, they
decrease the resources available to the program. Residents
living near the poverty
level, who would have been qualified for the program, might be
excluded because of a
lack of resources. Medicaid fraud also reduces the quality of
treatment as dishonest
providers try to reduce costs and increase personal profit. To
compensate for the
fraud, the state must either decrease services in other areas or
raise taxes.
HOW CAN I SPOT MEDICAID FRAUD?
Many of the cases prosecuted by the MFCU start with information
from the public.
Here are several hints to help detect fraud:
if a provider suggests treatment or services that you do not
realistically believe are necessary, be cautious of the
recommendation;
if you receive Medicaid and are in a healthcare facility,
check your personal funds account regularly;
if you are visiting in a healthcare facility, pay attention
to the patient's appearance and the appearance of the room and
the facility or any other indication of neglect.
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Victim Contact Information
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Last Updated: Thursday, 18-Oct-2007 18:19:19 EDT
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