When a healthcare professional or facility falsifies information to have Medicaid pay for medical services, that is Medicaid fraud.
In 1979, the Texas government created the Texas Medicaid Fraud Control Unit as an extension of the Office of the Attorney General to investigate a number of offenses categorized as Medicaid fraud.
The Medicaid Fraud Control Unit investigates cases of abuse and neglect occurring in facilities, such as nursing homes, funded through the Medicaid program. It also investigates Medicaid providers suspected of criminal fraud and helps authorities prosecute at the federal and local levels.
Examples of Medicaid fraud by healthcare professionals
Doctors, nurses, home health agencies, nursing home bookkeepers, ambulance companies, pharmacists, and health clinics may all commit Medicaid fraud. Examples are:
- Stealing funds from the expense account of a nursing home resident
- Billing for medical procedures without performing them
- Falsely diagnosing a patient to justify unnecessary tests
- Billing both the patient and Medicaid for the same services
- Transporting patients in an ambulance when unnecessary
- Billing for a name brand drug after giving the patient the generic version
The repercussions for Medicaid fraud vary based on the offense.
Examples of Medicaid fraud by members
Members may also commit fraud in a number of ways:
- Filing a claim for a service not received
- Shopping doctors for multiple prescriptions
- Altering receipts
- Using another member’s Medicaid ID
Doctors and other healthcare professionals that commit Medicaid fraud risk serious consequences for their lives and careers, and facilities that participate in abuse risk criminal charges and permanent shutdown.