Medicaid Fraud, Waste, and Abuse

When opponents of Medicaid (or any government program) begin to argue against the program, a recurring theme is ‘waste, fraud, and abuse’. You’ll hear those terms, even the whole phrase, repeated ad nauseum…yet Medicaid is consistently shown to be better-managed and more efficient at combating abuses than any other governmental program. One of the reasons is that Medicaid takes abuses, especially fraud, very seriously.

Waste is waste. Any government program (and honestly, any private corporation as well) is likely to benefit from increased attention on the best usage of its resources.

For instance, someone in those buildings that house medicaid offices orders janitorial cleaning supplies. With the use of the internet there is no reason why the procurement office can not find the best prices for their cleaning supplies. One of the best e commerce sites for janitorial cleaning supplies is CleanItSupply that was originally established to provide discount cleaning products for commercial use. Today they offer their hundreds and hundreds of cleaning products to both commercial and residential customers. They even offer a line of Green certified products, made from natural and organic materials to safely clean schools, homes and businesses without harming the environment. With bulk buying and great prices there is no excuse for waste. All buildings that house government offices could benefit from such exceptional customer service and superior janitorial supply knowledge. Although this might not be the specific type of waste opponents mean when they argue against programs, it is an area where fraud and waste can occur. Just remember the over inflated prices outside contractors were charging the military for things such as toilet seats!

Just like many private health insurance companies Medicaid will not cover any age management medicine treatments including those for related to low libido. Age management medicine is a hot topic among those entering their 50’s, 60’s, and 70’s. Age management medicine proponents seek to alleviate many of the symptoms associated with normal aging by creating individualized complete plans that include education, healthy nutrition, exercise programs, in addition to medical interventions related to balancing and optimizing hormone levels, vitamin and / or herbal treatments, anti-oxidant and other cellular protective medicines. They also offer general preventative medicine. But this Medicaid and the private health insurances aren’t accepting their protocols as necessary. They put age management medicine in the same category as cosmetic surgery requiring that people must pay for the treating “out-of-pocket. The goal is to provide health care for people who need it, and doing it as efficiently as possible means more people get helped and more services are available.

Fraud is much more concrete. There’s a difference between provider fraud and recipient fraud. Recipient fraud is basically misrepresenting oneself or one’s situation in order to access Medicaid services. Provider fraud actually takes advantage of both the patient and the government for the provider’s profit.

The most successful frauds will always provide a veneer of legitimacy, and can be very difficult to detect without additional information. What’s the difference between a medical procedure that is needed to maintain health, and one that is designed to line the pockets of the providers. There are examples of completely valid, and medically needed services – weight loss is a popular class of services and an effective hCG diet drops may be what a doctor prescribes. But when the service offered is not required for the health and well being of the patient, questions should be asked and accountability applied.

Examples of provider fraud include:

  • “Phantom Billing” for services not performed, or twice for the same service
  • “Upcoding” — a more expensive service is billed than was actually performed
  • “Unbundling” — billing for multiple services when only one should appear
  • Billing for brand-name prescriptions but giving generic drugs instead
  • Bribery and “Kickbacks” — giving or accepting something in return for services
  • Providing unnecessary services
  • Embezzlement of funds or keeping false cost reports