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Medicaid Fraud FAQ

What is Medicaid Fraud?

What is Resident Abuse, Neglect and Financial Exploitation?


What is Medicaid Fraud?

Examples of Medicaid Fraud:

  • Billing for services not rendered: A provider bills Medicaid for a procedure or service that was not actually provided.
  • Billing for upcoded services: A provider misrepresents the diagnosis and symptoms on patient records or selects higher paying procedure codes to obtain greater reimbursement than allowed.
  • Billing for uncovered services: A provider bills Medicaid for a service that requires the use of licensed or certified personnel but uses unqualified staff.
  • Drug substitution: A pharmacist fills a recipient's prescription with a generic drug, but bills Medicaid for a higher cost brand name drug.
  • Kickbacks: A provider offers or pays a kickback to induce someone to refer Medicaid recipients to that provider as patients or clients. Examples of kickbacks include cash, vacations, and gifts.
  • Supplemental Charges: A provider charges a Medicaid recipient for a service which is covered by Medicaid and should be billed to Medicaid, and then charges the recipient the difference between the provider's usual fee and what Medicaid pays.
  • Inflating the Usual and Customary Charges: A provider charges Medicaid more than their usual and customary charge for the same product or service billed to other insurers and the public. A provider might inflate the cost of the procedure, service or goods provided.

back to topWhat is Resident Abuse, Neglect and Financial Exploitation?

Resident abuse or neglect is any action or failure to act that causes unjustifiable harm to a healthcare facility resident. It includes physically assaulting a resident as well as withholding necessary food, care, or medical treatment. The Unit investigates reports of abuse and neglect in any in-patient or residential healthcare setting, including hospitals, nursing homes, and assisted living facilities.

Resident financial exploitation is the illegal or improper use of the funds or assets of a healthcare facility resident. It includes the misuse of personal funds held at the facility and may also include the misuse of funds by a resident's designated financial agent.

 


New Hampshire Department of Justice | 33 Capitol Street | Concord, NH | 03301
Telephone: 603-271-3658