Medicaid Provider Fraud

Medicaid provider fraudWhen we get sick, the first thing that we do is ask for professional help, without even admitting that we might become victims of a Medicaid Provider Fraud. Medicaid providers, as a symbol of care and custody, usually inspire trust and confidence, making us expect that our provider will supply us nothing, but help.

Unfortunately, statistics say that Medicaid Provider Fraud is a well-spread phenomenon among scammers, which steal billions of dollars annually. Moreover, the Federal Government also counts on physicians to submit accurate and truthful claims information, by creating such programs as Medicare, Medicaid, and other health care policies. Let’s have a deeper insight into the concept of this type of fraud and analyze the possible countermeasures.


First of all, every member of the health care community (individual, corporation, or other entity paid by Medicaid) can potentially become a scammer, including nurses, nurse aides, nursing homes, pharmacies, ambulance and transportation companies, chiropractors, podiatrists, licensed professional counselors, community care service providers, dentists, hospitals, medical equipment companies, speech therapists and others.

Among designated health services, we can list physical therapy, occupational therapy, outpatient speech-language pathology services; radiology and certain other imaging services; radiation therapy services and supplies, DME and supplies, parenteral and enteral nutrients equipment; prosthetics, orthopedics; outpatient prescription drugs; inpatient and outpatient hospital services. Concerning these points, even if your physician looks honest and trustworthy, consider paying attention to important details that we will mention below, in order to protect your pocket and your health.


As can be seen, the American Health Care System is a very tempting target for thieves and a large variety of health care programs makes it even more attractive. Medicaid, for example, is a health care program, created by the federal government, but directed by the state. It is designed to support payment for medical services for low-income citizens: those who either don’t have a medical insurance or have inadequate medical insurance and it bills $600 each year. Similarly, Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, or individuals with end-stage renal disease (permanent kidney failure that requires dialysis or a transplant).

A recent study, performed by Andrew Hackbarth and Donald Berwick (a former head of the Centers for Medicare and Medicaid Systems), evaluated the Medicaid fraud (and the suitable inspections and countermeasures) coming up to 10% from the total Medicaid expense (approx. $80 billion).

To emphasize the relevance of this issue, we would like to give you the following examples:

In May of 2014, 107 healthcare providers, along with doctors and nurses were arrested in several cities.

On Aug. 25, 2015 in Manhattan, NW, Oscar Huachillo, former owner and operator of NY Health Clinics, was sentenced for a $30 million Medicare Fraud Scheme.

On July 10, 2015, a Michigan oncologist, Fadrid Fata, was sentenced to 540 months in prison and ordered to forfeit $17.6 million for Health Care Fraud.

On July 7, 2015 Kentucky Doctor Visa Haran Sivasubramaniam, was sentenced for Tax Fraud claiming millions in fraudulent business expenses. (etc.)


Most health care providers do their best to supply a good service and take care of their patients, but we may encounter in our way physicians that use their position with the intention to get illegal personal gain. This trickery involves knowingly submitting false statements, making misrepresentations of the facts to obtain a federal health care payment for which no entitlement would otherwise exist.

It can be associated with following examples:

  • Billing for more hours in a day than there are; for nonexistent patients or patients of other providers; for services that were performed by an improperly supervised or unqualified employee; for services that were performed by an employee who has been excluded from participation in the federal health care programs; for unnecessary Services or Tests, for medical goods or services that were not provided or billing separately for services already included in a global fee, like billing for an evaluation and management service the day after surgery;
  • Up-coding services - using a billing code with a higher reimbursement rate than the service rendered;
  • Using telemarketing or door-to-door sales;
  • Telling you that the more test you perform, the less you pay;
  • Offering gifts as encouragement to use their services;
  • Claiming that Medicare endorses their products or services;
  • Double-billing for services not provided;
  • Using false credentials/ double-billing for healthcare goods or services not provided;
  • False Cost Reports;
  • Paying a “kickback’ in exchange for a referral for medical goods or services.

In order to avoid being a victim you should consider taking care of your medical provider’s behavior: like reviewing your Medicaid bill carefully to ensure charges and dates of service are correct, asking for a copy of everything you sign, being suspicious of anyone offering free tests or screening in exchange for your Medicaid card number, ensure accuracy when submitting bills or claims for services rendered, submit appropriate referral and treatment forms, report lost or stolen prescription pads.


The federal and state law doesn’t tolerate fraud, applying following sanctions: licensure and certification revocation or suspension, attorney fees, investigative costs, fines, restitution, jail and community control, civil false claim action, federal exclusion from participating in federally funded health care programs.

In case that you, or your loved ones have been charged with Medicaid fraud, consider hiring a qualified attorney to handle your case. Legal Bistro is here to help you find the perfect solutions for your concerns. All you have to do is go to Legal Bistro, create an account and describe your case. Let qualified attorneys help you go through this nightmare.

Note: You remain anonymous until you decide to reveal your identity to the lawyer you choose. It is 100% free for consumers so you have nothing to lose. Good luck!

Our motto is "When Lawyers Compete You Win!" If you are a consumer in need of legal services, you can post your case anonymously and Free of Charge. If you are an attorney seeking new clients, you may register on the site for free. You will only pay when a client requests that you contact them to discuss their case.

Leave a Reply

Your email address will not be published. Required fields are marked *

seven + 9 =

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>