Medicaid Fraud Definitions

Medicaid Fraud

When any provider of health care has defrauded the state Medicaid system. Providers include hospitals, nursing homes, pharmacies, laboratories, doctors, dentists and anyone else who is paid by Medicaid for a health care service.

Fraud is intentional deception or misrepresentation which results in an unearned benefit, usually in the form of an excess payment  While health care fraud can take many forms, the most common involve billing for services not performed or billing for more expensive services than those actually provided. Other forms of fraud include billing Medicaid at a higher rate than the rate charged a patient who is covered by insurance or who pays the bill himself or herself and billing a patient or patient’s family for a service Medicaid has already paid for, even if the Medicaid payment was less than the usual charge for the service.

Medicaid patients may not suspect fraud, as they are seldom made aware of the procedures or dollar amounts billed to Medicaid.

An unscrupulous provider can generate a fraudulent Medicaid payment simply by filing a false claim with an eligible recipient's identification number and a valid procedure code.

Patient abuse

The intentional or negligent infliction of physical pain, physical injury or mental injury.

Patient neglect

Failure of a caretaker to provide food, clothing, shelter or medical care in such a manner as to jeopardize the life, health and safety of the vulnerable adult.

Patient exploitation

An action that may include the misuse of funds, property or resources.

Misappropriation of patients' private funds

When any provider has misappropriated money belonging to a patient in a hospital, nursing home or other health care facility that receives Medicaid funds.

File a report with the Medicaid Fraud Unit
Definitions of Medicaid Fraud Resources for Senior Citizens