Program Integrity – Medicare/Medicaid Fraud, Waste and Abuse

October 28th, 2013

Medicaid Fraud:

Fraud and abuse in Medicaid cost states billions of dollars every year, diverting funds that could otherwise be used for legitimate health care services. Not only do fraudulent and abusive practices increase the cost of Medicaid without adding value – they increase risk and potential harm to patients who are exposed to unnecessary procedures. As states look for innovative ways to contain burgeoning Medicaid costs, fighting fraud and abuse offers one approach that everyone can support.

While Medicaid fraud involves knowingly misrepresenting the truth to obtain unauthorized benefit, abuse includes any practice that is inconsistent with acceptable fiscal, business or medical practices that unnecessarily increase costs. Waste is a related, though somewhat different issue, which encompasses overutilization of resources and inaccurate payments for services, such as unintentional duplicate payments.

North Carolina Man Defrauded Medicaid Program
A North Carolina man used Medicaid provider numbers of at least three licensed clinicians who performed some work for his company. With those numbers, he allegedly sought reimbursement for services that the counselors did not provide.

Although employees of Peaceful Alternative Services sometimes provided services for Medicaid recipients, the services typically were not provided by licensed professionals, prosecutors alleged. In addition, the government alleged, Robinson’s company often provided little more than mentoring services, which Medicaid does not reimburse.

Prosecutors say Robinson admitted he had schemed to defraud Medicaid by turning in reimbursement claims for mental and behavioral health services. Those claims came through Peaceful Alternative Services Inc., a company Robinson owned that operated from offices in Charlotte, Mooresville and Greensboro. Investigators claim Robinson used the money in part to buy luxury vehicles and jewelry.