Individuals and companies can face criminal prosecution for overbilling insurance companies and government medical programs for patient services. The federal government certifies Medicaid Fraud Control Units in Wisconsin and nearly all other states investigate fraud in federally-funded health care programs.
MFCU investigations focus on wrongdoing by health care providers rather than fraudulent activities by Medicaid recipients. Allegations may be brought separately against medical professionals, the businesses they own or the places that employ them like nursing homes, hospitals, pharmacies and drug makers.
Medicaid fraud investigators look for discrepancies between the services and procedures a patient receives and the claims submitted to Medicaid. A suspicious bill would contain a service a patient never had. An MFCU investigator might interpret that as a sign of fraud when in fact the mistake could be a simple, correctable accounting error.
Human error also can be responsible for double billing situations, when an insurance company or patient and Medicaid receive separate bills for the same medical service. Prosecutors' must show the defendant intended to defraud Medicaid, not only that a medical bill was incorrect.
MFCU investigators look for patterns of fraud like unusual billing hours and bills for pharmacy prescription medications that don't stack up against generic drugs supplied to patients. Investigators also check to make sure health care facilities aren't billing for tests or procedures a patient didn't need or for more costly services than were provided.
Investigators and prosecutors go after health care facilities engaged in kickback schemes with medical product or service providers. The MFCU also conducts investigations when medical professionals are suspected of manipulating Medicaid bills for personal gain.
Governments have plentiful resources to investigate crimes. That can be intimidating for people associated with or employed by a doctor or facility accused of illegal Medicaid billing practices. For the most effective representation, when possible, speak with a criminal defense attorney before talking to any government investigator.
Source: National Association of Medicaid Fraud Control Units, "What is Medicaid Fraud?," accessed May. 06, 2015