Medicaid fraud and abuse are a reality in our country, unfortunately. The abuse costs billions every year because of the funds that are diverted from the program and not used for legitimate health care services. As our Ashland Medicaid attorney can tell you, the fraud and abuse ultimately increase the cost of Medicaid. It also increases the risk of detriment to patients who are unknowingly subjected to unnecessary medical procedures and medications. Here is what you need to know in order to recognize Medicaid fraud and avoid it.
Understanding Medicaid fraud and abuse
Medicaid fraud refers to intentional misrepresentations made for the purpose of obtaining unauthorized Medicaid benefits. Fraud of this kind can be committed by health care providers and patients. Medicaid abuse refers to practices that contradict the acceptable business or medical practices which unnecessarily increase the cost of those expenses and the cost of Medicaid coverage.
What are examples of Medicaid fraud committed by health care providers?
Medicaid fraud does not only involve the actions of the patient, but also the actions of health care providers. Some of the more commonly seen incidents of provider fraud include the following:
- Submitting bills for services that were not actually performed
- Submitting duplicate bills for the same services provided
- Making a false diagnosis in order to obtain payment
- Billing for a more expensive service than what was actually performed
- Receiving kickbacks for patient referrals from other providers
- Submitting bills for covered services when non-covered services were actually provided
- Ordering inappropriate or excessive labs and other tests
- Prescribing medications that are not medically necessary
As a patient, you can learn to recognize health care provider fraud. For one thing, when you receive any type of health care service, you should keep notes about the dates for that service and also keep the receipts or billing statements you receive from your health care providers. Then, you will be able to compare the information you maintain with the statements you receive from Medicaid.
What are some examples of Medicaid fraud committed by patients?
Our Ashland Medicaid attorney understands that clients need to be careful to avoid committing Medicaid fraud themselves. Here are some common examples of Medicaid fraud committed by patients:
- Submitting a claim with Medicaid for services or products you did not receive
- Submitting forged or altered receipts for reimbursement from Medicaid
- Receiving medication or products you don’t need and selling them for profit
- Applying for services with false information
- “Shopping” for doctors to obtain multiple prescriptions
- Non-Medicaid recipients using someone else’s Medicaid coverage
Many people commit Medicaid fraud without knowing it. In order to avoid these types of actions, let our Ashland Medicaid attorney point out at least one important thing you can do. First, you should never request a service or treatment from your doctor that you do not actually require. That also means, don’t let anyone else convince you that you need to see a doctor when nothing is wrong.
Understanding Medicaid eligibility
One of the most common things that get clients in trouble is the belief that they should give away their property to family members before they apply for Medicaid. This is because Medicaid has asset limitations when it comes to eligibility. Specifically, Medicaid allows a recipient to have no more than $2,000 in “countable” assets. However, that does not mean you must exhaust all of your financial resources on long-term care and other medical expenses before you can receive Medicaid coverage.
How to avoid the appearance of a fraudulent transfer
The problem with attaining Medicaid eligibility is that you are not allowed to just give away all of your assets to someone else and then apply for Medicaid. If you do, there is a great chance that a penalty will be imposed. That is why it is important to discuss an appropriate Medicaid plan with our Ashland Medicaid attorney.
Understanding the Medicaid 5-year look back period
There is one law regarding Medicaid that clients should be aware of. In 2005, a statute was passed that created a period of ineligibility for some applicants who have given away their property at any point during the five-year period prior to their application. In light of this law, the timing of your transfers is crucial. For that reason, you need the assistance of an Ashland Medicaid attorney in creating a proper Medicaid plan.
How the five-year look back penalty works
Let’s assume you give away $5,000 worth of assets to relatives and this transfer occurred four and a half months prior to submitting your application. The so-called “look back” period will begin when you submit your application not when you made the gift. Additionally, the length of the penalty period is based on the value of the property that you gave away. But, with proper Medicaid planning, you will be able to maintain eligibility while protecting your assets and avoiding fraudulent transfers.
You may have planning options to preserve assets even within the five-year look back period
Even if you have not planned five years in advance of needing nursing home care, Medicaid’s complex rules may allow you to protect some assets while still qualifying for assistance. The key is to talk with an elder law attorney before the money has been spent. With proper Medicaid planning, you may legally be able to become eligible while still protecting some assets depending on your individual circumstances.
The penalty period only applies to application for long-term benefits
One common misconception is that the five-year look-back period applies to all types of Medicaid benefits. The reality is, the penalty period only applies to Medicaid coverage for long-term care expenses in a facility or long-term home health care. Conversely, acute care services in a hospital or physician services are not subject to the penalty period.
Join us for a FREE seminar today! If you have questions regarding Medicaid fraud or any other Medicaid planning matters, please contact the experienced attorneys at the Potter Law Firm for a consultation. You can contact us either online or by calling us at (606) 324-5516 (Ashland, KY), (859-372-6655 (Florence, KY), or (704) 944-3245 (Charlotte, NC). We are here to help!
John’s practice focuses on the use of Wills and Living Trusts in Estate Planning to help individuals protect their families and preserve their legacies after their deaths, but his practice also focuses on the critical issues of protecting individuals with dementia or other diminished capacity, assisting individuals in qualifying for Medicaid and other government benefits to offset the costs of long-term care, and providing special needs planning.
John is admitted to practice law in North Carolina, South Carolina, Kentucky, and Ohio, and he is accredited by the Department of Veterans Affairs.
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