Medicaid fraud is a serious problem in the United States. Now, it’s being reported that Louisiana recovered over $124 million in fraudulent payments in the Medicaid program in 2012. We have the highest recovery rate in the country.
Certainly some people may be accused of fraud, but how do the Louisiana Department of Health and Hospitals and Attorney General’s Office make sure they aren’t accusing the wrong people?
According to the Department of Health and Hospitals, investigations by the Medicaid Program Integrity Division identify possible fraudulent activities. Then investigators try to distinguish between billing errors and true fraud. If billing fraud is suspected, the investigation continues. If billing errors are more likely, then the business’ staff is trained on the correct billing practices.
In 2013, investigations resulted in 186 referrals to the Attorney General’s Medicaid Fraud Control Unit. It wasn’t reported how many others were investigated and later found innocent of the accusations.
States do not always win their Medicaid fraud cases. One investigation, which took place in Texas, claimed that a provider had billed up to $1 million to Medicaid fraudulently. The state allegedly did not have enough evidence to prove fraud and was told so by the court. However, the funds were not released. Some suggest that indicates that doctors and other medical providers are presumed guilty rather than innocent, as the law demands.
When a health care provider is accused of fraud, funds may be withheld by the government. States are required to withhold payments if there is a credible reason to believe fraud has taken place, but if not, that money should be paid to the provider.
Source: Department of Health & Hospitals – State of Louisiana, “Louisiana Leads the Nation in Medicaid Fraud Recovery Rates” Jul. 21, 2014