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Department of Health Care Finance
 

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What is Fraud?

Hands exchanging money

Examples of Provider Fraud

Billing for services not rendered 
Billing for services not medically necessary
"Upcoding" or inappropriate billing that results in a loss to the Medicaid program
Inappropriate or lack of documentation to support services billed
Quality of care issues that fail to meet professionally recognized health care standards
Falsifying certificates of medical necessity, plans of treatment, and medical records to justify payment
Soliciting or receiving kickbacks; and/or ,
Violating Medicaid policies, procedures, rules, regulations, and/or statutes
 

Examples of Recipient Fraud

Excessive use or overuse of Medicaid 
Using another's Medicaid Identification card
Lending, altering or duplicating a Medicaid ID
Providing incorrect eligibility or false information to a provider to obtain treatment
Simultaneously receiving benefits in DC and another state
Knowingly assisting providers in rendering services to defraud the Medicaid program.  For example, it is illegal for a recipient to accept a payment of any type in exchange for signing a time sheet for Personal Care Assistance Services that have not been provided.  
Prescription fraud