Frequently asked questions about Medicaid Fraud
Click to report medicaid fraud.
The Attorney General's Office investigates fraud or abuse committed by providers of services (such as doctors, dentists or home health agencies) to Medicaid participants, formerly known as recipients. The Attorney General's Office does not have statutory authority to investigate fraud committed by Medicaid participants (such as persons who may be concealing income to receive Medicaid services). The Department of Social Services has that authority. Complaints regarding participant eligibility should be sent to the Department of Social Services.
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 report Medicaid provider fraud or abuse and neglect?
- How can I qualify as a Medicaid fraud whistleblower?
- Who do I contact if I suspect Medicaid participant 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 the reimbursement from Missouri Medicaid, provider fraud has occurred. See examples below.
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What are some examples of provider fraud?
- Billing for any 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;
- Billing for unnecessary services;
- False cost reports;
- Embezzlement of participant funds; and
- Falsifying timesheets or signatures in connection with the provision of personal care services.
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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 Medicaid Fraud Control Unit has recovered more than $137 million dollars since January 2009. The unit does not investigate fraud committed by participants.
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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 to honest providers and participants in other areas or raise taxes.
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How can I spot Medicaid fraud?
Many of the cases prosecuted by the Medicaid Fraud Control 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 participant, 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 participant who is in a nursing home or other health care facility, check the participant'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 report Medicaid provider fraud or abuse and neglect?
The Attorney General's Office does not have statutory authority to investigate fraud committed by Medicaid participants (such as persons who may be concealing income to receive Medicaid services). The Department of Social Services has that authority. Complaints regarding participant eligibility may be sent to the Department of Social Services. The Attorney General's Office investigates fraud or abuse committed by providers of services (such as doctors, dentists or home health agencies) to Medicaid participants.
You may report Medicaid provider fraud or abuse and neglect by using any of the following methods:
- Call toll free at (800) 286-3932
- Email attorney.general@ago.mo.gov
- Download, complete, and mail a complaint form to:
Click to report medicaid fraud.
Missouri Attorney General's Office
Medicaid Fraud Control Unit
P.O. Box 899
Jefferson City, MO 65102
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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 or email attorney.general@ago.mo.gov.
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Who do I contact if I suspect Medicaid participant fraud?
Contact Department of Social Services, Division of Legal Services — Investigations Unit at (877) 770-8055, 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?
Contact the Department of Social Services, MO HealthNet Division at (888) 275-5908.
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