The Colorado Medicaid system pays billions of dollars annually to provide health care to the State’s neediest citizens. Medicaid provider fraud costs taxpayers millions of dollars and takes money away from children and adults who genuinely require it for their health.
Medicaid Fraud is an attempt to obtain more benefits or payments than you are entitled to by means of a willful false statement, a willful misrepresentation, concealing material facts, or by a fraudulent scheme.
The following examples are a small sampling of the types of fraudulent schemes providers have attempted:
- Billing for services, drugs, supplies or equipment that were not furnished, or were of lower quality;
- Substituting or misrepresenting the items billed;
- Repeated billing for purportedly covered items, which were not actually covered;
- Ordering unnecessary services;
- Incorrect coding, i.e., supplying a regular office visit but billing for something more;
- Calling for the Medicaid recipient to come back to the provider's office, even when it's obvious additional appointments are not necessary;
- Providing a set amount of services based on time and then billing for more time than was really provided;
- Billing for office visits that didn't actually occur;
- Payment of kickbacks for the referral of a recipient to a provider; or
- Medical identity theft.
How can I spot Medicaid fraud?
If you receive an Explanation of Benefits (EOB) from Medicaid, read it carefully. If the information is not correct or is different than the services you received, contact the Medicaid office shown on the bill.
If a provider suggests treatments or services that you do not believe are necessary, it’s okay to be cautious of the recommendation and to ask for a second opinion.
What if I suspect a provider is committing or has committed fraud?
The mere suspicion that a medical provider may have received or tried to receive Medicaid payments in excess of legally allowable amounts is all that is needed as a basis to make a report of suspected fraud.
If you suspect a provider is committing or has committed fraud, report it immediately. Call the Colorado Attorney General's Medicaid Fraud Control Unit at 720-508-6696, or file a complaint online.
Fraud by Individuals Who Receive Services
The MFCU does not investigate individuals who receive services as part of the Medicaid Program.
The local county office of Human Services typically investigates recipient fraud, and the local District Attorney’s Office prosecutes those individuals who practice fraudulent schemes. Recipient fraud can be:
- Falsifying information on applications in order to receive benefits;
- Loaning your Medicaid ID card to others;
- Changing or faking an order or prescription;
- Using more than one Medicaid ID number;
- Deliberately getting duplicate or excessive services and/or supplies.
If you know or suspect recipient fraud is being committed, please contact the local department of Human Services office in the county where the recipient is receiving services.
Employers and Excluded Individuals
Employers who participate in the Medicaid program are required to ensure that their employees, subcontractors, and vendors haven’t been excluded or disqualified from the Medicaid program.
When excluded, no program payment will be made for anything an excluded person or entity provides. This applies to the excluded person, anyone who employs or contracts with the excluded person and any facility where the excluded person provides services, regardless of who submits the claims.
Employers and contractors should check the U.S. Department of Health and Human Services, Office of the Inspector General Exclusion Database periodically to make sure they are not billing Medicaid for services associated with an excluded individual or entity. Failure to do so may result in a civil penalty for each claim submitted.