Medicaid Fraud, Waste and Abuse

Medicaid fraud, waste and abuse can be committed by both providers and participants of the Medicaid program.

Provider Fraud, Waste and Abuse

Provider fraud is generally the result of an intentional misrepresentation of services rendered. While the fraud, waste and abuse may take on many forms, some of the more common are:

  • Billing for services when no service was provided (“phantom billing”).
  • Billing for a more expensive treatment or service than was actually provided (“upcoding”).
  • Billing for unnecessary services.
  • Billing for the same service multiple times.
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Other forms of fraud include the receipt of kickbacks, such as receiving anything of value (cash, free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies, physicians referring patients to obtain services from a Medicaid provider whom the physician or physician’s immediate family member has a financial relationship).

Participant Fraud, Waste and Abuse

Fraud and abuse in the Medicaid program is not limited only to the provider side of the service equation. Unfortunately, participants have also engaged in behavior that results in the defrauding of the program. Some of the participant forms of fraud, waste and abuse include:

  • Signing documentation (i.e. timesheets) indicating services were provided when not provided.
  • Selling prescription medications obtained through the Medicaid program.
  • Forging prescriptions to obtain medications.
  • Allowing someone other than the card holder to utilize a Medicaid card.
  • Falsifying information to qualify for Medicaid services. (Contact Welfare Investigations Unit)