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When to speak up: identifying and reporting Medicaid fraud

On Behalf of | Dec 20, 2023 | Medicare / Medicaid Fraud

As a Medicaid recipient, you have the right to receive necessary medical care and services that help improve your health and well-being. However, sometimes, health care providers may bill for services that are not medically necessary or may upcode (bill for more expensive services than what you received). This can result in unnecessary costs to the Medicaid program and it may fall under Medicaid fraud.

What is challenging is that if you do not know much about medical terms, may be difficult to differentiate between essential services and nonessential. It is important to know the clear lines that define these categories to clearly demarcate what qualifies as necessary and what may be a potential fraud.

Examples of unnecessary billing for medical services

Below are some examples of medical order or tests and services that go beyond what is medically necessary for the patient’s well-being.

  • Ordering frequent and repetitive MRI scans for a stable
  • Performing unnecessary CT scans for minor injuries
  • Ordering multiple blood tests for a patient without a clear medical indication
  • Conducting frequent and redundant urinalysis for a stable condition
  • Scheduling unnecessary specialist consultations without a valid medical reason or referral.
  • Repeatedly seeking consultations for a well-managed chronic condition without clear complications

Recognizing and addressing these practices is crucial for preserving the effectiveness and financial sustainability of the Medicaid program. But what if you really need those tests?

How would you know you are receiving unnecessary services?

It can be challenging to distinguish between necessary and unnecessary medical services. While some tests may seem excessive, they often play a crucial role in accurately diagnosing a patient’s condition and ensuring their well-being. It is important to remember that medical professionals thoroughly approach diagnosis and treatment to ensure the best possible outcomes for their patients.

This is why it is essential to ask questions. Inquire about the reason behind specific tests or procedures. You may also seek a second opinion to confirm the necessity of recommended services.

What to do if you suspect Medicaid fraud:

If you suspect Medicaid fraud, it is a civic duty to report it. Here are the steps to report possible fraudulent activity:

  • Contact Medicaid: Reach out to your state’s Medicaid office with detailed information about the suspected fraud. Provide dates, services and any evidence you may have.
  • Use hotlines: Many states offer hotlines for reporting fraud anonymously. Check your state’s Medicaid website for the appropriate contact information.

However, it is essential to document any evidence you have to prove that the act is indeed fraudulent. Remember, health care professionals may administer services that may appear irrelevant to a patient’s condition. But there are times that they are necessary to ensure accurate diagnosis and treatment. You may want to seek legal advice from a qui tam attorney. They can help you determine if what you have will be enough to receive a whistleblower reward for reporting fraudulent actions.

By reporting potential Medicaid fraud, you contribute to the overall well-being of the health care system and ensure that resources are allocated where they are genuinely needed.