Attorney General Alan Wilson targets fraud in the health care industry through the Medicaid Fraud Control Unit (MFCU).
Title XIX of the Social Security Act created the Medicaid program. Medicaid is a governmentally funded (federal and state matching) health insurance program for the low-income, disabled and elderly. In 1977, the Medicare/Medicaid Anti-Fraud and Abuse Amendment was adopted, which created a nationwide system of Medicaid Fraud Control Units.
The MFCU also investigates and prosecutes physical abuse, neglect, and exploitation of certain vulnerable adults.
Medicaid provider fraud occurs when a Medicaid provider knowingly makes a false or misleading statement in order to be reimbursed from the Medicaid program.
The MFCU recovers taxpayer money by identifying, investigating, and prosecuting fraud committed by hospitals, nursing homes, clinical laboratories, pharmacies, doctors, nurses, home and respite care providers, transportation services, 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’ Office of the Inspector General (HHS OIG) to exclude individuals or entities from participating in federally-funded programs.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)
Medicaid recipients, their family members, and people who care for them can help combat Medicaid provider fraud by monitoring Beneficiary Explanations of Medicaid Benefits and using caution when providing a Medicaid ID number.
Keep a lookout for unusual activity, such as:
- charges for services that were never performed, or for goods you never received.
- charges from a person or business you are unfamiliar with.
- multiple billings for the same service.
- services that were not ordered by your doctor.
- individuals who offer money or goods in exchange for your Medicaid ID number.
Providers who defraud the Medicaid program not only steal from the taxpayers at large, but also harm those populations eligible for benefits, such as by assigning a fictitious diagnosis in order to receive reimbursement for bogus claims, or by billing a beneficiary’s maximum allowed service amount, precluding that beneficiary from receiving treatment from a legitimate provider.
Vulnerable adult abuse or neglect occurs when a person or caregiver knowingly causes physical harm or fails to provide proper medical services to a Medicaid recipient living at home, or any resident living in a health care facility. Vulnerable adult financial exploitation occurs when a person steals money or property belonging to a resident of a facility.
MFCU enforces South Carolina laws protecting Medicaid beneficiaries and vulnerable adults from neglect, abuse, and exploitation. Under South Carolina law, a Vulnerable Adult is someone eighteen years of age or older who has a physical or mental condition which substantially impairs the person from adequately providing for his or her own care or protection. This includes a person whose impairment is based on advanced age. A resident of a long-term care facility, such as an assisted living facility or nursing home, is a vulnerable adult. The MFCU is also permitted to investigate and prosecute allegations of abuse, neglect, and exploitation of Medicaid beneficiaries living at home.
The MFCU investigates and, if appropriate, prosecutes individuals who abuse vulnerable adults and individuals who unlawfully use funds or assets of vulnerable adults.
What are typical forms of patient abuse, neglect, and exploitation?
- Intentionally deviating from the standard of care to such a degree that serious physical injury or death occurs.
- Using physical force or restraints outside the course of approved medical treatment.
- Diverting prescription drugs for the benefit of someone other than the patient.
- Utilizing a patient’s financial resources without permission, particularly when such use is not for the patient’s benefit.
How can I spot patient abuse?
Individuals, their family members, and people who care for them can help combat abuse, neglect, and exploitation by monitoring:
- The appearance any bruises, welts, lacerations, broken bones or burns; particularly when those injuries are inconsistent with the explanation for how they occurred
- Any significant changes in behavior that cause the individual to become fearful, mistrustful, withdrawn, or agitated.
- Unusual financial transactions, particularly when someone else has access to the individual’s bank account or credit card and the transactions are for large sums, appear routinely, or are for goods or services the individual does not use.
Where can I learn more?
The MFCU operates pursuant to a federal grant program operated by the Medicaid Fraud Unit Oversight Division located in the Office of Evaluations and Inspections of the United States Department of Health and Human Services’ Office of Inspector General (HHS-OIG). Additional information on the Unit’s jurisdiction and performance may be found at OIG.HHS.gov.
Information on the South Carolina Medicaid program and its commitment to maintaining program integrity may be found at SCDHHS.gov.
The MFCU is a member of the Adult Protection Coordinating Council (APCC). The APCC is comprised of numerous public and private entities whose mission is to foster coordination and cooperation in a combined effort to protect South Carolina’s Vulnerable Adults. Information on the APCC’s structure and services may be found at SCDHHS.gov.
If you have any information about Medicaid Provider Fraud or Patient Abuse, please report it to Attorney General Alan Wilson’s Medicaid Fraud Control Unit at: SCMFCU@scag.gov; (803) 734-3660 or call toll-free: 1-888-NO-CHEAT (1-888-662-4328) Tips can be made anonymously but reporters are encouraged to provide specific information if possible.
Or Mail Complaint to:
South Carolina Attorney General’s Office
Medicaid Fraud Control Unit
Post Office Box 11549
Columbia, SC 29211-1549