Things You Should Know About Healthcare Programs Recipient Fraud

medicaid fraudEasy money have always been an attractive incentive for the majority of people. Some of us, are more likely to think that a little fraud will not lead to serious cases of criminal prosecution. For those who could not resist temptation – here are several things you should know about Medicaid Recipient Fraud.

Let’s start with explaining what Medicaid and Medicare programs are, and what is the difference between these two concepts. The Federal Government designed these two healthcare programs in order to help, defeat and supply medical services for the underprivileged members of our society - either those who do not have an adequate medical insurance, or those who do not have it at allMedicaid is a program designed for low-income citizens, regardless of age, who can’t be eligible for an adequate health care insurance due to their financial incapacity. It is a federal program, managed by the state, unlike Medicare, which is another healthcare federal program with uniform, national rules. It is of assistance for people over 65 regardless of their income, younger disabled people and dialysis patients (with any age with end-stage renal disease, or a kidney transplant). Some people can be eligible for both Medicare and Medicaid, being called “dual eligibles”. Under these circumstances, most health care costs are likely covered.

healthcare fraud

The quantum of health care usage involve the numbers of individuals served, units of service (days of care, medication prescribed), the size of services (charge per person or per unit of service, average length of stay), coverage categoriestypes of service, demographic and geographic variables. Despite the fact that the federal government is making everything possible to defend its citizens, some of us decide that stealing money from the taxpayers could be an easy way to escape some payments. The agency conceived to investigate and combat Medicaid Recipient Fraud is the U.S. Health Department’s Office of Medicaid Management. It is created to protect healthcare federal programs from external abuse and recover inappropriate Medicaid payments.

Here are several specific examples of a Medicaid Recipient Fraud:

  • Selling or buying a Medicaid card;
  • Participating in doctor and pharmacy fishing;
  • Submitting a false application for Medicaid or using more than one Medicaid IDs;
  • Providing inaccurate information regarding income, family members or any other related information;
  • Sharing the Medicaid card with another person;
  • Re-selling medicine or other products obtained with Medicaid benefits;
  • Getting services for which you are not eligible;
  • Changing or faking an order or prescription;
  • Billing errors, claiming processing errors, misalignment of payment policies;
  • Falsifying a prescription or an order;
  • Duplicating services or receiving excessive supplies.

Statistics say that Medicaid Recipient Fraud appears to be on rise. Generally, the approximate cost of health care spending comes to $3.2 trillion in 2015. Tens of billions of dollars are spent in the fraud mechanism. It has to be mentioned that Medicare and Medicaid are high-risk programs, because of their magnitude and data complexity. The U.S Department of Justice recovered more that $15 billion in healthcare-fraud cases in the last five years. About $80 billion were spent on improper payments across federal programs.

In order to protect Medicaid and Medicare integrity, following countermeasures were conceived: reviewing the credentials of individuals applying; monitoring recipient pharmaceutical utilization; post-enrollment audits; provider audits; health personnel training; outreaching stakeholders; improving basic techniques in Medicaid Fraud Detection Programs; providing care seminars, emerging trends in Medicaid and Medicare; updating policies and regulations, etc.

Fraud prosecution is a complex system designed to ensure that taxpayers’ dollars are spent effectively and appropriately. The penalties for this misdemeanor can be very serious, depending on the amount of fraud, and can include civil monetary fines; garnishment of your wages; exclusion from Healthcare programs; prison sentence; restitution orders; liens on any property that you own; deportation (if you’re an immigrant).

In case that you are now prosecuted for Medicaid Recipient Fraud you have to take adequate actions. First of all, you have to find a qualified attorney that will handle your case, because any wrong step that you can do on your own will be used against you in court. Then you have to find out what the crime you under investigation for, and do not verbally or physically assault the officer. Try to remain cooperative, but do not make any statements on your own. Legal Bistro is here to provide you the best protection. All you have to do is create your account and describe your case.

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