Medicaid Fraud Nuts and Bolts

What is Medicaid? Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources.


What is Georgia Medicaid? Medicaid is a “medical assistance program that helps many people who cannot afford medical care pay for some or all of their medical bills. Medicaid is administered by the Georgia Department of Community Health and pays medical bills with state and federal tax money.”

What is Medicaid Fraud?

Medicaid Fraud can come in many different forms – some elaborate and some not so elaborate.

What are some types of fraud?

-Billing for Unnecessary Services or Items -Intentionally billing for unnecessary medical services or items.
-Billing for Services or Items Not Provided – Intentionally billing for services or items not provided.
-Unbundling Billing for multiple codes for a group of procedures that are covered in a single global billing code.
-Upcoding Billing for services at a higher level of complexity than provided.
-Card Sharing -Knowingly treating and claiming reimbursement for someone other than the eligible beneficiary.
-Collusion – Knowingly collaborating with beneficiaries to file false claims
for reimbursement.
Kickbacks -Offering, soliciting, or paying for beneficiary referrals for
medical services or items.
Program Eligibility – Knowingly billing for an ineligible beneficiary

Who prosecutes these cases?

The DOJ’s Health Care Unit. or in Georgia, the Georgia Medical Fraud Division of the Office of the Attorney General

What are some examples of prosecutions?

Opioid prosecutions

National Health Care Fraud Enforcement – “The Department of Justice announced today criminal charges against 138 defendants, including 42 doctors, nurses, and other licensed medical professionals, in 31 federal districts across the United States for their alleged participation in various health care fraud schemes that resulted in approximately $1.4 billion in alleged losses.”

In the 2019 Operation Brace yourself prosecution press release, the DOJ had a call to action stating, “Any doctors or medical professionals who have been involved with alleged fraudulent telemedicine and DME marketing schemes – including Video Doctor USA, AffordADoc, Web Doctors Plus, Integrated Support Plus and First Care MD should call to report this conduct to the FBI.  Nope, call a lawyer first!

Conaway & Strickler, PC has experienced healthcare fraud defense lawyers ready to assist if you receive a subpoena, a “friendly visit by agents”, a request for some patient files, or an interview request from the Medicaid Fraud Control Unit.  Contact us to learn more – do not go at this alone.



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