Frequently asked questions of the Medicaid Fraud Control Unit
Table of Contents
- What is Medicaid?
- What is Medicaid provider fraud?
- What are some examples of provider fraud?
- What does the Attorney General's Medicaid Fraud Control Unit do?
- How does Medicaid provider fraud affect me?
- How can I spot Medicaid fraud?
- How can I qualify as a Medicaid fraud whistleblower?
- How can I report Medicaid provider fraud or abuse and neglect?
- Who do I contact if I suspect Medicaid recipient fraud?
- Who do I contact for other Medicaid questions?
What is Medicaid?
Medicaid is a federal/state cost-sharing program that provides health care to people who are unable to pay for such care. The Missouri Department of Social Services administers the Missouri Medicaid program.
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What is Medicaid provider fraud?
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 Missouri Medicaid, provider fraud has occurred.
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What are some examples of provider fraud?
- Billing for medical services not actually performed, known as phantom billing;
- Billing for a more expensive service than was actually rendered, known as upcoding;
- Billing for several services that should be combined into one billing, known as unbundling;
- 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, known as a kickback;
- Bribery;
- Providing unnecessary services;
- False cost reports; and
- Embezzlement of recipient funds.
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What does the Attorney General's Medicaid Fraud Control Unit do?
The unit conducts fraud and abuse/neglect investigations on health care providers receiving payments from the Medicaid program. The unit does not investigate fraud committed by recipients.
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How does Medicaid provider fraud affect me?
When providers steal from Missouri Medicaid, they decrease the resources available to the program. Medicaid fraud also reduces the quality of treatment as dishonest providers try to reduce costs and increase personal profit. To compensate for the fraud, the state must either decrease services in other areas or raise taxes.
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How can I spot Medicaid fraud?
Many of the cases prosecuted by the unit start with information from private citizens. If a provider suggests treatment or services that you do not realistically believe are necessary, be cautious of the recommendation. If you are a recipient, be wary of "free" tests, services, or medical products offered in exchange for your Medicaid information. If you are the legal guardian of a Medicaid recipient who is in a nursing home or other health care facility, check the recipient's personal funds account regularly. If you are visiting in a nursing home or other health care facility, pay attention to the patient's appearance and the appearance of the room for any indication of abuse or neglect.
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How can I qualify as a Medicaid fraud whistleblower?
Section 191.907 of the Revised Statutes of Missouri allows any person who reports MO HealthNet fraud to receive 10 percent of the amount recovered by the state through the use of that person's information. To qualify for this incentive, you must meet three criteria:
- You must be the original source of information, meaning the information must not be already known to the government or public;
- You must not have planned, initiated or participated in the fraud being reported; and
- The information you submit must be used by the Attorney General to bring a civil action for recovery of expenditures made by the MO HealthNet Program.
You may call the Medicaid Fraud Hotline toll free at 800-286-3932, email ag@ago.mo.gov, or download, complete, and mail a complaint form to:
Missouri Attorney General's Office
Medicaid Fraud Control Unit
P.O. Box 899
Jefferson City, MO 65102
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How can I report Medicaid provider fraud or abuse and neglect?
You may call the Medicaid Fraud Hotline toll free at 800-286-3932, or email ag@ago.mo.gov.
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Who do I contact if I suspect Medicaid recipient fraud?
You need to contact Department of Social Services, Division of Legal Services — Investigations Unit at 573-751-3285, or you can e-mail the complaint to ask.mhd@dss.mo.gov.
You may also send the complaint in writing to:
Department of Social Services
Division of Legal Services — Investigations Unit
P.O. Box 1527
Jefferson City, MO 65109
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Who do I contact for other Medicaid questions?
You need to contact the Department of Social Services, MO HealthNet Division at 573-751-3425.
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