Medicaid Fraud - Oregon Department of Justice : Consumer Protection

Medicaid Fraud

The Oregon DOJ’s Medicaid Fraud Unit (MFU) conducts state-wide investigations and prosecutions against health care providers who defraud the Medicaid program.

What is Medicaid?

The Oregon Health Plan, Oregon’s Medicaid program, is a government program that provides health care to our vulnerable population – including low-income senior citizens and mentally, physically and developmentally disabled adults. Medicaid is administered by the state but funded from both federal and state dollars.

Although they sound similar, Medicaid and Medicare are not the same thing. Medicare is a federally funded and administered program which provides health insurance for people 65 and over, and for some people under 65 with certain disabilities or conditions. See https://www.medicare.gov/ » for more info about Medicare.

What is Medicaid Fraud?

MFUs investigate all types of Medicaid funded health care providers including in-home caregivers, licensed practitioners (such as physicians, dentists and therapists), medical clinics, hospitals, nursing homes and pharmaceutical manufacturers.

Generally, Medicaid fraud occurs when a provider misrepresents the services rendered to receive increased reimbursement from the Medicaid program.

Typical Medicaid Fraud schemes include:

“Phantom Billing” – Billing for services or goods that were never provided.
Double Billing – Multiple providers billing Medicaid for the same services for the same recipient.
Upcoding – Billing for a more expensive service or good than what was provided.
Billing for Unnecessary Services – Billing for services or goods that a patient does not need.

How To Spot Medicaid Fraud

Medicaid recipients, their family members and people who care for them, can help combat Medicaid fraud by monitoring medical billing statements and looking out 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.

Abuse, Neglect and Misappropriation of Funds

The MFU also investigates and prosecutes allegations of abuse, neglect and misappropriation of funds in health care facilities that receive Medicaid funds or when the victim is a Medicaid recipient and the misconduct is done in the connection of the delivery of health care services or goods.

Abuse: Assaultive acts (e.g. slapping, punching, choking, etc.) to include sexual abuse.
Neglect: The withholding of necessary food, care, shelter, or medical treatment.
Misappropriation of Funds: The illegal or improper use of a patient’s funds or assets.