The Missouri Attorney General’s Office welcomes citizens’ assistance in fighting health care fraud and abuse/neglect of Medicaid recipients and residents/patients in healthcare facilities. If you suspect fraud or abuse/neglect please complete the Complaint form or call the hotline number 1-800-286-3932.
Medicaid is a health care insurance program available to those who cannot afford medical services including low-income families, children, disabled individuals, and the elderly. In Missouri, Managed Care Organizations (MCOs) such as Home State Health, HealthyBlue, and United HealthCare help administer the Medicaid program in many areas of the State. In many cases, the MCO help coordinate care to the Medicaid recipients in their coverage areas.
What is Medicaid fraud and how does it affect me?
When healthcare providers, including Managed Care Providers, steal or take from Missouri Medicaid they are stealing tax payer dollars and reducing the resources available to help those in need. Reporting and fighting Medicaid fraud as well as abuse and neglect is in everyone’s best interest.
Medicaid fraud at its most basic is when a healthcare provider submits a bill for healthcare services they did not provide. Missouri’s healthcare fraud law states, “No health care provider shall knowingly make or cause to be made a false statement or false representation of a material fact in order to receive a health care payment…” §191.905.1, RSMo.
Insider Information
The Missouri enacted §191.907 which provides a whistleblower or insider with knowledge, known in Missouri as the “original source of information”, with ten percent (10%) of the recovery.
Specifically, “Any person who is the original source of the information used by the attorney general to bring an action under subsection 14 of section 191.905 shall receive ten percent of any recovery by the attorney general.” The “original source of information” means information no part of which has been previously disclosed to or known by the government or public.
The Missouri Attorney General intends to reward citizens who come forward with information about providers who are stealing taxpayer dollars from Missouri Citizens and Missouri Medicaid.
Medicaid Fraud Control Unit (MFCU)
MFCU is made up of investigators, nurses, auditors, computer analysts, lawyers and staff that specialize in investigating and prosecuting fraud and abuse/neglect cases.
Fraud
MFCU prosecutes healthcare providers who steal your tax dollars by claiming they provided healthcare services when in fact they did not or provided services of a lesser value than they claim.
The MFCU investigates and prosecutes those who prey on the needy and vulnerable, holding them accountable and protecting taxpayer dollars. The MFCU team vigorously investigates fraud allegations as well as elder abuse and neglect, with the goal of deterring fraudulent and abusive activities throughout Missouri through its criminal prosecutions and civil lawsuits.
Examples of Healthcare Providers:
- Hospitals
- Doctors
- Pharmacists
- Medical transportation companies such as taxi/van service providers
- Home Health providers (e.g., personal care attendants)
- Durable Medical Equipment suppliers – i.e. wheelchairs, prosthetics, adult diapers
- Nursing Homes
- Medical Laboratories
- Home Infusion Treatment Companies
- Dentists
- Rehabilitation Providers
- Counselors/therapists
- Federally Qualified Health Center (FQHC)
- Rural Health Clinic
- Hospice
Healthcare fraud schemes include:
- Billing for Services Not Provided – A provider bills for services not performed, such as blood tests or x-rays that were not taken, full denture plates when only partial ones are supplied, or a nursing home or hospital that continues to bill for services rendered to a patient who is no longer at the facility either because of death or transfer.
- Double Billing – A provider bills both Medicaid and a private insurance company (or the recipient) for treatment, or two providers request payment on the same recipient for the same procedure on the same date.
- Billing for Phantom Patient Visits – A provider falsely bills the Medicaid program for patient visits that never take place.
- Billing for More Hours than there are in a Day – A psychiatrist inflates the amount of time he spends with his patients – billing for more than 24 hours of psychotherapy treatment in a day.
- Falsifying Claim Information – Claiming to have provided services actually performed by someone else. An example would include a physician who claims to have provided medical services to a patient when the services were actually performed by unlicensed staff. Another example would be a hospital billing for services of a specialist when the service was actually performed by an unlicensed medical student.
- Billing for brand name drugs and substituting generics or billing for drugs not actually dispensed.
- Billing for Unnecessary Services or Tests – A provider falsifies the diagnosis or symptoms on recipient records and billings to obtain payments for unnecessary laboratory tests or equipment.
- Billing for More Expensive Procedures Than Were Performed – A provider bills for a comprehensive procedure when only a limited one was administered or billing for expensive equipment and actually furnishing cheap substitutes.
- Kickbacks – A nursing home owner or operator requires another provider, such as a laboratory, ambulance company, or a pharmacy, to pay the owner/operator a certain portion of the money received for rendering services to patients in the nursing home. This practice usually results in unnecessary services being performed to generate the additional income to pay the kickbacks.
- False Cost Reports – A nursing home owner or operator claims higher staff levels or more sophisticated equipment than are actually present at the facility.
Abuse/Neglect
The Unit also investigates allegations of patient/resident abuse or neglect in health care facilities such as long-term care facilities, nursing homes, residential care facilities and hospitals as well as complaints of the misappropriation of patients’ private funds.
The MFCU investigates complaints of abuse or neglect against patients and residents in health care facilities that receive federal funds including complaints of the misappropriation of patient’s private funds in facilities such as long-term care facilities, nursing homes, residential care facilities and hospitals.
Patient abuse or neglect occurs when a person or caregiver knowingly causes physical harm to a resident of a health care facility or fails to give a resident needed medical service. For example, the MFCU has investigated and prosecuted allegations of sexual abuse of residential care residents, drug diversion and failing to provide necessary care that caused the resident harm.
Signs of Elder Abuse and Neglect
- Burns, welts, scratches, bruises, cuts
- Resident/Patient is dirty, unclean and unkept
- Fractures, dislocations, sprains
- Restraints, tied to bed or chair
- Mistrust of others
- Showing “fear” when specific staff are around
- Unsanitary or unsafe housing
- Inappropriate or inadequate clothing
- Malnourishment
- Lack of needed supervision
- Untreated medical condition
- Lack of needed dentures, glasses, hearing aids or medication
- Stating that they are being neglected or abused