Medicaid Fraud Law & Legal Definition

Medicaid fraud is the providing of false information to claim medical reimbursements beyond the scope of payment for actual health care services rendered.

Generally Medicaid providers include doctors, dentists, hospitals, nursing homes, pharmacies, clinics, counselors, personal care/homemaker chore companies, and any other individual or company that is paid by the Medicaid program. If a provider intentionally misrepresents the services rendered, and therefore increases their reimbursement from Medicaid provider fraud has occurred. Examples of some provider fraud are

• Billing for medical services not actually performed;
• Billing for a more expensive service than was actually rendered;
• Billing for several services that should be combined into one billing;
• Billing twice for the same medical service;
• Dispensing generic drugs and billing for brand-name drugs;
• Giving or accepting something in return for medical services;
• Bribery
• Providing unnecessary services;
• False cost reports; and
• Embezzlement of recipient funds.

Example of a state statute ( Louisiana) on Medicaid fraud

La. R.S. 14:70.1

§ 14:70.1. Medicaid fraud

A. The crime of Medicaid fraud is the act of any person, who, with intent to defraud the state through any medical assistance program created under the federal Social Security Act and administered by the Department of Health and Hospitals:

(1) Presents for allowance or payment any false or fraudulent claim for furnishing services or merchandise; or

(2) Knowingly submits false information for the purpose of obtaining greater compensation than that to which he is legally entitled for furnishing services or merchandise; or

(3) Knowingly submits false information for the purpose of obtaining authorization for furnishing services or merchandise.

B. Whoever commits the crime of Medicaid fraud shall be imprisoned, with or without hard labor, for not more than five years, or may be fined not more than twenty thousand dollars, or both.