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Medicaid fraud: A problem for patients, care providers, insurers

Medicaid provides necessary health coverage to many people in the United States. It provides coverage to the elderly, pregnant women, children, low-income adults and many others. Not everyone is able to qualify for Medicaid.

One possible fraudulent act that could occur involving Medicaid is lying to obtain the benefits. Someone could potentially show that they don't earn as much as they do or claim an injury or illness that they don't have to obtain benefits. Knowingly misrepresenting yourself to obtain unauthorized benefits is against the law and can lead to significant penalties.

Medicaid waste, abuse and fraud costs the United States billions of dollars yearly. Medicaid fraud doesn't just involve patients who may claim that they have conditions that they don't. It can also include providers seeking compensation for procedures that were not necessary or never performed at all.

Whether you're a person claiming that you should qualify for Medicaid or a medical provider putting through a request for reimbursement from Medicaid, you must be cautious to follow the rules of the benefits system.

What are common kinds of Medicaid fraud?

There are three kinds of Medicaid fraud including:

  • Patient fraud
  • Provider fraud
  • Insurer fraud

With patient fraud, patients may:

  • Seek benefits for services that weren't received
  • Alter receipts or forge receipts to obtain higher payments
  • Seek medications and then sell them on the black market
  • Provide false information to obtain Medicaid
  • Use insurance coverage that someone else was given for their own services

With provider fraud, some actions that may occur include:

  • Falsifying a patient's diagnosis
  • Accepting kickbacks for referrals
  • Prescribing unnecessary medications
  • Billing more than once for the same services
  • Billing for services that were not provided

Finally, insurer fraud may occur when:

  • Insurers mislead enrollees about the plan's benefits
  • Valid claims are denied unfairly
  • The amount owed by the insurer is undervalued, leaving the health care provider without full compensation

In any case, Medicaid fraud and abuse can lead to significant penalties for individuals, whether they're insurance agents, medical providers or patients.

The good news for you is that an accusation of fraud may not be accurate. You have an opportunity to defend yourself. For any action to constitute fraud, it will need to be shown that you knowingly participated in the fraudulent act. If there was a mistake made, such as duplicate billing, then the likelihood is that fraud was not the case, and you should not face the same types of penalties.

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