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Medicaid/Medicare Recipient Fraud
A Medicaid recipient may face a medicaid fraud investigation as well as criminal charges due to any of the following: Stating false facts on the application to receive medicaid despite being ineligible; Loaning Medicaid to another person; Forging or altering a prescription or fiscal order; Using multiple Medicaid cards; Intentionally receiving duplicative, excessive, contraindicated or conflicting health care services or supplies; and Re-selling items provided by the Medicaid program.
Medicaid/Medicare Provider (Medical Office) Fraud

A provider may face a fraud investigation or criminal charges for any of the following:

Billing for services that were not provided, e.g., a chest x-ray that was not taken; Duplicate billing which occurs when a provider bills Medicaid and also bills private insurance and/or the recipient; Requiring the recipient to return to the office for more visits when another appointment is not necessary; Taking unnecessary x-rays, blood work, etc.; Upcoding, e.g., providing a simple office visit and billing for a comprehensive visit; Having an unlicensed person perform services that only a licensed professional should render, and bills as if the professional provided the service; Billing for more time than actually provided, i.e., counseling, anesthesia, etc.; Billing for an office visit when there was none, or adding additional family members' names to bills; and, Accepting payment from another provider, including sharing in the reimbursement paid by the Medicaid program, as a result of referring a patient to the other provider.

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