What is Medicare And Medicaid Fraud

Medicare and Medicaid fraud refer to illegal practices aimed at getting unfairly high payouts from government-funded healthcare programs.

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Medicare Vs. Medicaid

BREAKING DOWN Medicare And Medicaid Fraud

Medicare and Medicaid fraud can be committed by medical professionals or healthcare facilities, patients or program participants, and outside parties who may pretend to be one of these parties.

There are many types of Medicare and Medicaid fraud. Common examples include:

  • billing for services that weren't provided, in the form of phantom billing and upcoding
  • performing unnecessary tests or giving unnecessary referrals, which is known as ping-ponging
  • charging separately for services that are usually charged at a package rate, known as unbundling
  • abusing or mistreating patients
  • patients or participants who receive benefits for which they are not eligible, by means of fraud or deception, or by not correctly reporting assets, income or other financial information
  • filing claims for reimbursement for which the claimant is not legitimately entitled
  • committing identity theft to receive services by pretending to be someone who is eligible to receive services

The Challenges of Fighting Medicare and Medicaid Fraud

Medicare and Medicaid fraud are a multi-billion dollar drain on a system that is already expensive to maintain. The departments that oversee these programs have internal staff members who are charged with monitoring activities for signs of fraud. In addition, there are also external auditors who are responsible for reviewing suspicious claim patterns.

These entities that provide investigation and oversight related to potential fraud include the Medicaid Fraud Control Units, or MFCUs, which operate in 49 states and the District of Columbia. Most of the MFCUs operate as part of the Attorney General’s office in that state, and must be independent and separate from the state’s Medicaid office.

In an effort to help prevent fraud that is related to identity theft, Medicare implemented a new program in the spring of 2018. Beginning in April 2018, Medicare participants would begin receiving new ID cards. These new ID cards would now include a Medicare Number, instead of the participant’s Social Security number.

Detecting and preventing fraud is an important priority for the people and departments that oversee these critical programs, because the wasted funds that are lost to fraud and other illegal tactics represent resources that could be used to support participants who need assistance.