The unfortunate reality is that Medicaid fraud and abuse, which violates Medicaid law, does happen and it costs billions of dollars each year in diverted funds that should have been used for legitimate health care services. Because of the fraud and abuse, the cost of Medicaid is higher, as is the risk of harm to patients who are unwittingly exposed to unnecessary medical procedures.
Medicaid fraud and Medicaid abuse
Medicaid fraud happens when someone knowingly misrepresents the truth in order to obtain unauthorized benefits. This type of fraud can be committed by patients as well as health care providers. Medicaid abuse, however, includes any practice that is inconsistent with acceptable economic, business or medical practices and that unnecessarily increase costs. Both type of misconduct violates Medicaid law.
Common examples of patient fraud that violates Medicaid law
Some common examples of patient fraud include filing a claim for Medicaid services or medical products that are not actually received by the recipient, altering or forging receipts in order to receive reimbursement from Medicaid, and obtaining medications or medical equipment that is not actually needed and then selling those items on the black market. Also, providing false information when completing an application for Medicaid services is a violation of Medicaid law. Shopping for doctors so you can obtain several prescriptions for the same medication is also against the law.
In order to avoid unwittingly committing fraud, there are a few things you should not do. First, refrain from contacting your doctor to request a service that you do not really require. Also, never let anyone convince you to see a doctor for medical care or services you don’t need.
Common examples of health care provider fraud
Medicaid fraud is not only seen in the actions of the patient. It can also be committed by health care service providers. Here are some common examples of Medicaid fraud by health care providers which violates Medicaid law.
- Billing for medical services not actually performed
- Submitting duplicate billing for the same service
- Submitting a false diagnosis
- Billing for a more expensive services than were actually performed
- Receiving kickbacks for referring patients
- Billing for covered Medicaid services when a non-covered service was actually provided
- Ordering excessive or unnecessary tests
- Prescribing medication that is not medically required
There are several ways to recognize when provider fraud is occurring with regard to your medical care. For one thing, whenever you obtain health care services, keep a record of the dates you receive those services and save the receipts and statements you obtain from providers. That way you can compare the dates and services listed in your records with the statements you receive from Medicaid.
How to avoid the appearance of fraudulent transfers
A common misconception that many people share is that they will be required to give away all of their assets in order to qualify for Medicaid, if they need long-term care. As a result of this misconception, most people think they can simply transfer their property to their family members in order to protect their eligibility for Medicaid. The issue is that you cannot simply give your property away before you submit your application for Medicaid.
Medicaid law imposes a 5-year look back period
A law was passed in 2005 establishing a period of ineligibility to be applied to everyone who gives away their property at any time within five years of submitting their application for Medicaid benefits. Because the period of ineligibility begins when you actually apply for Medicaid, the timing of the transfers is key. That is why estate planning, and especially Medicaid planning is so important.
How the penalty period works
If a potential Medicaid applicant gives $10,000 of his estate to a family member four years and six months before submitting the application, the period of ineligibility begins when the application is submitted, not when the gift was made. The period of ineligibility is referred to as the “penalty period” or the “five-year lookback period.” The length of the penalty period will depend on the value of the assets that were transferred. With careful Medicaid planning, you can still retain control of your property while maintaining your eligibility for Medicaid benefits.
The penalty period doesn’t apply in every situation
The five year penalty period does not apply in every situation. Whether you have to wait to receive benefits depends on your specific situation. The Medicaid penalty period is only applicable for long-term care expenses in an institutional setting. On the other hand, acute care including hospital or physician services, is generally not affected by the five-year look back period.
Download our FREE estate planning worksheet today! If you have questions regarding Medicaid law, or any other elder law matters, contact Gaughan & Connealy for a consultation either online or by calling us at (913) 262-2000.