Re: Examples of Medicaid Provider Fraud
- From: "Jerry Okamura" <okamuraj005@xxxxxxxxxxxxx>
- Date: Tue, 10 Mar 2009 08:47:27 -1000
Sutton is famously known for answering a reporter, Mitch Ohnstad, who asked why he robbed banks by saying, "because that's where the money is."
"Raymond" <Bluerhymer@xxxxxxx> wrote in message news:c7c54fe8-0ae5-4e01-81c0-a1f18b55e2bf@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
Examples of Medicaid Provider Fraud
http://www.michigan.gov/ag/0,1607,7-164-17334_18152-46063--,00.html
DOCTORS
DENTISTS
CHIROPRACTORS
PODIATRISTS
OPTOMETRISTS
NURSING HOMES
HOME HEALTH CARE
ADULT FOSTER CARE (AFC) HOMES
HOSPITALS
PSYCHIATRIC HOSPITALS
SUBSTANCE ABUSE CLINICS
PHARMACIES
DURABLE MEDICAL EQUIPMENT
LABORATORY SCAMS
KICKBACKS
MOBILE LABORATORIES
AMBULANCE SERVICES
--------------------------------------------------------------------------------
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.
http://www.michigan.gov/ag/0,1607,7-164-17334_18152-46063--,00.html
.
- References:
- Examples of Medicaid Provider Fraud
- From: Raymond
- Examples of Medicaid Provider Fraud
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