Medicaid clients and providers are a critical link in combating Medicaid fraud

November 12, 2024

Protecting program integrity in Medicaid requires everyone’s assistance. Clients, providers, insurers and government agencies must all work together to protect the state’s health care resources.

Currently, Medicaid and the Children’s Health Insurance Plan (CHIP) provide comprehensive medical coverage to more than four million Texans. When providers or clients defraud the program, it can result in a loss of access to benefits and services for all Medicaid beneficiaries as the state works to balance the health and human services budget against unexpected losses.

Medicaid clients
Medicaid and CHIP are in place to help Texans in need. Unfortunately, some attempt to receive services they do not qualify for or profit from the program. These illegal actions not only lead to costly repayments of benefits when the client is caught but can result in criminal charges.

Client investigations may begin if, among other factors, investigators find evidence of:

Falsified household composition, income and assets to qualify for Medicaid coverage.
Received cash, goods or services for selecting certain providers.
Received cash, goods or services in exchange for agreeing to receive non-medically necessary tests, equipment or supplies.

Providers
Providers have an obligation to report fraud or mistakes in your practice when discovered. Oftentimes, these can be unintended billing errors that are resolvable through the OIG’s self-disclosure process. Unfortunately, some look to profit by intentionally misleading their clients, managed care organizations and the State of Texas. One of the best ways to stop these bad actors is for other health care providers, including front office and support staff, or clients to report misdeeds when they occur.

Provider investigations may begin if, among other factors, investigators find evidence of:

Billing for more severe conditions than diagnosed to receive higher reimbursement.
Charging for the same service multiple times within the same period.
Billing for services that were never provided.
Misrepresented their credentials or providing services outside their scope of practice.
Stealing funds from long-term care client’s accounts for personal gain.
Ordering X-rays, labs or other tests not needed for the care or treatment of a patient.
Using ambulances for transportation when not medically necessary.
Billing for name-brand medications while dispensing generic medications.
Charging clients for services paid for by Medicaid.
Offering kickbacks to patients or other providers to use your organization.

Reporting fraud in Medicaid is not just about reclaiming funds. Medicaid is funded by Texas tax dollars to provide critical services to low-income residents. Breaking the public’s trust erodes program support, which could leave millions of Texans without access to care. If you suspect fraud in the Medicaid program, use the online OIG Fraud Reporting Form or call the OIG Fraud Hotline at 1-800-436-6184.