Medicaid Fraud and Abuse

Physical abuse of a patient occurs when any provider or employee of a Medicaid funded facility, such as nursing home or rest home, physically assaults any resident. The Medicaid Investigations Unit can investigate abuse whether or not it leads to serious injury. Even if the patient is not a Medicaid recipient, the MIU can investigate the abuse if the facility receives Medicaid funding.

Medicaid fraud occurs when a provider:

• Bills Medicaid for a service not actually provided to the patient
  
• Uses an improper procedure code to bill for a higher priced service when a lower priced service was provided.
  
• Bills for non-covered services by describing the services as covered services.
• Misrepresents a patient's diagnosis and symptoms and bills Medicaid for a service that is medically unnecessary
  
• Falsifies a cost report. An example of cost report fraud is when the owner of a facility lists personal expenses not related to direct patient care as if they were direct patient care costs in the facility's cost report. Another example is miscoding indirect costs as direct costs in order to obtain higher reimbursement.
  
• Falsifies medical records.
  
• Bills a Medicaid patient or family or a private insurance company for a service that Medicaid has already paid.
• Receives or gives an illegal kickback in return for referring a patient to a medical provider.
• Falsifies a physician's certificate of medical necessity (COM) and bills Medicaid for services that require a COM.
• Bills Medicaid for drugs dispensed without a lawful prescription.
• An employee of a home care provider submits false time sheets, which causes the provider to bill for services not rendered.

Embezzlement or theft from a patient

If a Medicaid funded facility or an employee of that facility steals money belonging to a resident, the Medicaid Investigations Unit can investigate. The MIU can investigate the embezzlement and theft of funds from both Medicaid recipients and private pay residents in facilities that receive Medicaid funds.

Commingling of patient and facility funds occurs when a Medicaid funded facility willfully deposits a resident's funds into the facility's operating account for use by the facility. By unlawfully commingling, the facility makes the resident's funds available to pay the facility's operating expenses rather than maintaining the funds for the benefit of the resident. The MIU investigates the commingling of funds of both Medicaid recipients and non-Medicaid residents in facilities that receive Medicaid funds.