Health Care Fraud:
When a Medicaid provider submits false or fraudulent claims for payment of health care services.
If you are completing a complaint form or sending an email, provide us with as much detail as possible and a contact name, phone number or e-mail address. This will help us if we have additional questions regarding the information you submit.
Health care fraud is when a Medicaid provider submits false or fraudulent claims for payment of health care services.
Medicaid providers may be:
- Mental health or case management providers;
- Nursing homes;
- Transportation providers; or
- Any other provider who bills the Medicaid program for services.
When a provider or person is found to be involved in fraud or abuse the circumstances may warrant exclusion from participation in the Medicaid program. Once a provider or person is excluded from participation in Idaho Medicaid, they will also be referred to the Office of Inspector General (OIG) for exclusion from any federally funded healthcare program and their name will be published on a national exclusion list.
Providers or persons who have been excluded are prohibited from treating federal program clients or working for providers or entities who treat federal program clients:
Common Fraud Schemes
- Altering and/or falsifying records to match services billed
- Balance billing Medicaid clients for services above the Medicaid payment rate
- Billing for services not covered by Medicaid as covered services
- Billing mid-level services as physician services
- Billing services for patients who have died
- Changing the billed dates of service to match client dates of eligibility
- Deliberately applying for duplicate reimbursement in order to get paid twice
- Inappropriate billing that results in a loss to the Medicaid program
- Kickbacks — Providing gifts or incentives for the ability to provide service billed to the Medicaid program
- Providing service which is not medically necessary
- Unbundling — Billing related services separately to charge a higher amount than if combined and billed as one service/group of services/panel of services
- Upcoding — Providing a specific service and billing for a more expensive or detailed service
- Violating Medicaid and/or CHIP program policies, procedures, rules, regulations and/or statutes
Durable Medical Equipment
- Billing Medicaid for more expensive equipment than actually supplied
- Billing used items as new
- Continues to send medical supplies when no longer needed
- Billing for more hospital/nursing home days than delivered
- False cost reports
- Billing for services performed by unlicensed or unqualified persons
- Billing a greater amount of drugs than was actually dispensed
- Billing for drugs or refills not authorized by a physician
- Filling a prescription with a generic drug or over-the-counter drug but billing for a more expensive name-brand drug
- Billing for less mileage in an effort to circumvent the need to obtain prior approval
- Billing for more mileage than incurred
- Billing Medicaid for transportation to non-Medicaid services