Program Integrity: Report Fraud, Waste and Abuse

Fraud  is defined in Medicaid rules as “An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.  It includes any act that constitutes fraud under applicable federal or state law.”

Waste encompasses the over-utilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act.

Abuse is related to poor fiscal, business or medical practices that increase costs, such as reimbursement for services that are not medically necessary, coding errors, and other mistakes.  An honest mistake should lead to the return of funds to Medicaid.

Providers who improperly bill for services and beneficiaries who cause unnecessary costs, risk losing continued eligibility to participate in the Medicaid program and may face criminal and civil monetary penalties.

Some examples of fraud, waste and abuse include:

• A Medicaid client sharing his or her card with other people who are not entitled to receive Medicaid services;
• Billing for services not rendered;
• Modifying medical records;
• Utilizing unlicensed staff;
• Billing duplicate claims;
• Upcoding, etcetera…

Let us know if you’ve witnessed instances of fraud, waste and abuse!

• Provider and Member Education
• Pre and Post-payment Review of Claims
• Investigate Referrals / Complaints
• Medicaid Program Recommendations