Fraud is defined as an intentional deception or intentional
misrepresentation made by a person with the knowledge that the deception
could result in some unauthorized personal benefit or unauthorized benefit to
some other person. Fraud is dependent upon evidence that must prove
misrepresentation with intent to illegally obtain services, payment or other
gains.
Program abuse means provider practices that are inconsistent with sound
fiscal, business or medical practices, that result in unnecessary cost to
the Medicaid program, or that result in reimbursement for services which are
not medically necessary or that fail to meet professionally recognized
standards for health care.
Examples of provider fraud/abuse include:
- Billing for services or equipment that the patient did not
receive
- Charging recipients for services over and above that paid
for by Medicaid
- Double billing or other illegal billing practices
- Submitting false medical diplomas or licenses in order to
qualify as a Medicaid provider
- Ordering tests, prescriptions or procedures that patient
does not need
- Rebating or accepting a fee or a portion of a fee for a Medicaid patient referral
- Failing to repay or make arrangements for the repayment of
identified overpayments
- Physical, mental, emotional or sexual abuse of a patient
Examples of provider fraud/abuse include:
- Forging or altering a prescription
- Allowing others to use a Medicaid card to get services
- Failure to keep a Medicaid card safe
- Intentionally seeking and receiving excessive drugs,
services or supplies
- Collusion with providers in order to get services or
supplies
- Providing false information in order to qualify for Medicaid