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Examples of Medicaid Provider Fraud



DOCTORS:
: [Return To Provider Example List]

  • Bill for services not provided, i.e. a chest x-ray when an x-ray was not taken.
  • Duplicate Billing occurs when a provider bills Medicaid and the recipient or private insurance for the same service.
  • Requires that the patient come back each week for the same problem or to get the same prescription when another appointment is not necessary, or a normal amount of medication could be prescribed.
  • Upcode, i.e. identify a simple office visit as an emergency office visit or a comprehensive visit.
  • Take unnecessary x-rays, blood work or perform other unnecessary services.
  • Bill Medicaid for an office appointment when you did not have an appointment, or add additional family members' names for appointments.
  • Have an unlicensed person perform services that only a licensed professional should render, and bill as if the professional had provided the service.
  • Billing for more time than actually provided, ie counseling, anesthesia, etc.
  • Alter date of service for billing purposes.

DENTISTS: [Return To Provider Example List]

  • Bill Medicaid for services not provided, i.e. a mouth x-ray when an x-ray was not taken, or for a cleaning that was not performed.
  • Duplicate Billing occurs when a provider bills Medicaid and the recipient, or a private dental insurance for the same service.
  • Provides poor quality dentures that do not fit, then states that for a certain amount of money, he/she can make you a “good” pair. Medicaid provides for good dentures.
  • “Create” cavities to fill more teeth than need fixing, just to raise the reimbursement.
  • Fill only one cavity per visit to increase the copay per procedure.
  • Charge for services that supposedly aren’t covered by Medicaid, i.e. fluoride treatments. Fluoride treatments are a covered benefit for children.
  • Dentist will clean teeth, and charge extra to clean the patient’s gums.
  • Alter date of service for billing purposes.

CHIROPRACTORS: [Return To Provider Example List]

  • Upcode the severity of the injury.
  • Increase the number of adjustments made per visit.
  • Bill for office visits when no appointment is made.
  • Require a copayment.
  • Bill two insurance carriers for the same procedure.
  • Alter date of service for billing purposes.
  • Billing services provided by chiropractor under a doctor's ID number to increase reimbursement.

PODIATRISTS: [Return To Provider Example List]

  • Upcode, bill for a more expensive procedure than was actually performed, i.e. bill for surgery when the patient’s toe nails were trimmed.
  • Bill for services when no services were provided.
  • Visit a nursing home, and bill for treatments without being requested.

OPTOMETRISTS: [Return To Provider Example List]

  • Limit the number of glasses frames available to Medicaid clients, and tell them that they have to pay more for "attractive frames".
  • Require that Medicaid reimburse the optician before the glasses are ordered.
  • Demand a copay for services when the patient is under 21 years old.
  • Charge for services that supposedly aren’t covered by Medicaid, i.e. non scratch lenses. When approved by Medicaid, this is a covered service.
  • Charging for an extra Medicaid covered examination.

NURSING HOMES: [Return To Provider Example List]

  • Bill Medicaid for services not provided, i.e. a chest x-ray when an x-ray was not taken, food supplements not given, medications not distributed.
  • Bill Medicaid for a resident who is no longer eligible, or who is no longer at the facility due to death or discharge.
  • Kickbacks. Facility owner may require certain providers, such as pharmacies or laboratories, etc., to pay a certain portion of the money to the facility owner for access to the residents. Payment can take the form of cash, vacation trips or other compensation.
  • Providing generic medications when a specific name brand drug is ordered and billed.
  • Using the monthly Medicaid allotment of diapers/pads on non-Medicaid residents.

HOME HEALTH CARE: [Return To Provider Example List]

  • Agency billing for a home visit when none was provided.
  • Agency billing for a longer visit than provided.
  • Agency billing for a professional visit when an unskilled unlicensed person was sent to the home.
  • Agency billing for more services than were actually provided, i.e. bath, when no bath was given.

ADULT FOSTER CARE [AFC] HOMES: [Return To Provider Example List]

  • Billing for services not rendered, i.e. medical care needed but not provided.
  • Billing for more staff than actually are care providers. Including Administrators along with direct care staff to increase the payments from Medicaid.
  • Not providing licensed individuals to supervise, or understaffing.
  • Using the monthly Medicaid allotment of diapers/pads on a non-Medicaid resident.

HOSPITALS: [Return To Provider Example List]

  • Billing for services not rendered.
  • Substituting generic drugs and billing for name brand medications.
  • Substituting medical resident doctor services and billing for licensed medical practitioner services.
  • Billing for more days than actually used.
  • Billing for lab procedures not used.

PSYCHIATRIC HOSPITALS: [Return To Provider Example List]

  • Billing for counseling sessions not provided.
  • Upcoding the severity of the medical problem.
  • Billing for accommodations not used, private room versus a ward room.
  • Adding on time for a counseling session.
SUBSTANCE ABUSE CLINICS: [Return To Provider Example List]

  • Requiring a copay before each visit.
  • Billing for counseling sessions not provided.
  • Billing for one hour sessions when less counseling time is provided.
  • Using unlicensed counselors when a licensed counselor is required.

PHARMACIES: [Return To Provider Example List]

  • Substituting a generic for a name brand medication and billing for the name brand.
  • Providing fewer pills than prescribed, but billing for the entire number of medications prescribed.
  • Dispensing only part of the prescription in order to get another filling fee.
  • Requiring a higher copay.
DURABLE MEDICAL EQUIPMENT: [Return To Provider Example List]

  • Providing used or broken equipment and billing for new equipment.
  • Billing for equipment rental after the client has died or no longer needs the equipment.
  • Billing for rental when the client has paid for the product.
  • Billing for a more expensive item when a cheaper item was delivered.
  • Not picking up the item on time in order to get another month’s rental cost from Medicaid.
  • Billing for equipment not provided.
LABORATORY SCAMS: [Return To Provider Example List]

  • Bundling a series of tests, and then unbundling to individually bill certain tests to increase charges.
  • Adding unprescribed tests to a series of tests that were ordered.
  • Not doing the blood tests, but sending out results of another blood sample.

KICKBACKS: [Return To Provider Example List]

  • Provider refusing to do business with a supplier unless there is direct monetary compensation.
  • Certain commission sales in the medical profession are considered a kickback.

MOBILE LABORATORIES: [Return To Provider Example List]

  • Providing unnecessary tests, especially x-rays and blood work.
  • Billing for services not rendered.
  • Billing for patients who are not enrolled patients.

AMBULANCE SERVICES: [Return To Provider Example List]

  • Upcoding the quality of services needed, i.e. billing for life support services when transportation was all that was needed.
  • Changing hospital destinations to charge additional fees.
  • Charging for additional services not rendered, i.e. oxygen, monitors.
Related Content
 •  About The Health Care Fraud Division
 •  How To Identify & Report Medicaid Provider Fraud
 •  How To Document & Report Vulnerable Adult Abuse/Neglect
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