Medicare and Medicaid Fraud
Medicare and Medicaid fraud refer to illegal practices aimed at getting unfairly high payouts from government-funded healthcare programs. The CARES Act also: Increases flexibility for Medicare to cover telehealth services. Authorizes Medicare certification for home health services by physician assistants, nurse practitioners, and certified nurse specialists. Increases Medicare payments for COVID-19-related hospital stays and durable medical equipment. For Medicaid, the CARES Act clarifies that non-expansion states can use the Medicaid program to cover COVID-19-related services for uninsured adults who would have qualified for Medicaid if the state had chosen to expand. 2:07 Medicare and Medicaid fraud can be committed by medical professionals, healthcare facilities, patients or program participants, and outside parties who may pretend to be one of these parties. These entities that provide investigation and oversight related to potential fraud include the Medicaid Fraud Control Units, or MFCUs, which operate in 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Medicare and Medicaid fraud can be committed by medical professionals, healthcare facilities, patients, and others who pretend to be one of these parties.
What is Medicare and Medicaid Fraud?
Medicare and Medicaid fraud refer to illegal practices aimed at getting unfairly high payouts from government-funded healthcare programs.
Understanding Medicare and Medicaid Fraud
Medicare and Medicaid fraud can be committed by medical professionals, healthcare facilities, patients or program participants, and outside parties who may pretend to be one of these parties.
There are many types of Medicare and Medicaid fraud. Common examples include:
The Challenges of Fighting Medicare and Medicaid Fraud
Medicare and Medicaid fraud are a multibillion-dollar drain on a system that is already expensive to maintain. The departments that oversee these programs have internal staff members who are charged with monitoring activities for signs of fraud. In addition, there are also external auditors who are responsible for reviewing suspicious claim patterns.
These entities that provide investigation and oversight related to potential fraud include the Medicaid Fraud Control Units, or MFCUs, which operate in 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Most MFCUs operate as part of the Attorney General’s office in that state, and must be independent and separate from the state’s Medicaid office.
In an effort to help prevent fraud that is related to identity theft, Medicare implemented a new program in the spring of 2018. Beginning in April 2018, Medicare participants started to receive new ID cards that include a Medicare Number instead of the participant’s Social Security number.
Detecting and preventing fraud is an important priority for the people and departments that oversee these critical programs. The wasted funds that are lost to fraud and other illegal tactics represent resources that could be used to support participants who really need assistance.
The CARES Act of 2020
Related terms:
Custodial Care
Custodial care is non-medical care recommended by a medical professional that helps individuals with their daily basic care, such as eating and bathing. read more
Eldercare
Eldercare refers to services older people often need for physical or mental impairment. Here's what it covers and costs, and how insurance can help. read more
Long-Term Care Ombudsman
A long-term care ombudsman is an official who oversees nursing and assisted living facilities and is an expert in the associated laws and regulations. read more
Medicaid
Medicaid is a government-sponsored insurance program for individuals and families whose income is insufficient to cover health related services. read more
Medicare
Medicare is a U.S. government program providing healthcare insurance to individuals 65 and older or those under 65 who meet eligibility requirements. read more
Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare and Medicaid Services administers major healthcare programs in the U.S. It is part of the U.S. Department of Health and Human Services. read more