Medicaid Fraud

Attorney General Alan Wilson targets fraud in the health care industry through the Medicaid Fraud Control Unit.

The Medicaid Fraud Control Unit investigates and prosecutes health care fraud committed by Medicaid providers and the physical abuse of patients and embezzlement of patient funds in facilities.  SC MFCU enforces South Carolina laws protecting mentally or physically disabled or elderly citizens from neglect and abuse in long-term care facilities.

Recovering taxpayer money through successful Medicaid fraud prosecutions, the MFCU utilizes a team-based approach to identify and investigate frauds committed by hospitals, nursing homes, pharmacies, doctors, dentists, nurses and other Medicaid providers.

The MFCU has the authority to hold individuals or entities accountable through criminal prosecution and/or civil litigation. The Unit also makes recommendations to the US Department of Health and Human Services, Offices of the Inspector General (HHS OIG) to exclude individuals or entities from participating in federally-funded programs.

Since 2008, the SC MFCU has recovered over $62 million and helped win over 90 criminal convictions in health care fraud and abuses cases.

What is Medicaid?

The Medicaid program provides medical benefits to South Carolinians who cannot afford to pay for medical care. Though the federal government establishes general guidelines for the Medicaid program, each state establishes its own program, including eligibility criteria. The South Carolina Medicaid Program is funded through federal and state funds.

What is Medicaid Fraud?

Medicaid fraud occurs when a Medicaid provider knowingly makes, or causes to be made, a false or misleading statement or representation for use in obtaining reimbursement from the Medicaid program.

What are typical Medicaid fraud schemes?

Typical schemes by which individuals and corporations steal from the Medicaid program include:

  • Billing for services not rendered
  • Billing for medically unnecessary services
  • Upcoding (billing Medicaid for more expensive procedures than those that are actually performed)
  • Double-billing (billing both Medicaid and a private insurance company or the recipient directly, or multiple providers billing Medicaid for the same recipient for the same procedure on the same date)
  • Kickbacks (hidden financial arrangements between providers involving some material benefit in return for another provider prescribing or using their product or services, which frequently results in unnecessary treatment)

What is patient abuse or neglect?

Patient abuse or neglect occurs when a person or caregiver knowingly causes physical harm to a resident of a health care facility or fails to give a resident needed medical services.

If a person steals money belonging to a resident of a facility, the MFCU can investigate, and prosecute.

Report Medicaid Fraud.

If you have any information about Medicaid provider fraud or patient abuse, please report it to Attorney General Alan Wilson’s Medicaid Fraud Unit at: (803) 734-3660 or call toll-free: 1-888-NO-CHEAT (1-888-662-4328) Tips can be made anonymously.

 

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Columbia, SC

Rembert Dennis Building | 1000 Assembly Street,

Room 519 | Columbia, S.C. 29201

Phone: 1-803-734-3970 | Fax: (803) 253-6283

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