How to Spot Medicaid Fraud and Abuse

Be alert to possible signs of fraud or abuse, including:

Physical abuse:

• The resident has bruises, welts, lacerations, broken bones, or burns.
• The resident's injuries are inconsistent with the explanation of the injuries.
• The resident develops a significant unexplained change in behavior and becomes fearful, mistrustful, withdrawn, or agitated.
• The patient is pressured to receive unnecessary or excessive services.
• The patient's medical records are altered.
• The medical provider claims to provide services for free.
• The medical provider dispenses excessive amounts of controlled substances.

Financial abuse:

• The facility does not maintain a ledger (either in paper or electronic form) that shows information about the resident's personal spending.
• The facility does not maintain the personal funds of residents in a bank account that is separate from the facility's operating account (however, the funds of all residents may be kept together in one bank account).
• The ending balance in the facility's ledger showing the residents' personal funds spending does not match the ending balance in the bank statement for the residents' personal funds bank account.
• Large sums of money are withdrawn without the resident's knowledge.
• Checks are written or sums withdrawn for the purchase of items that would be of no use to the resident.