Blog: Fighting Medicaid Fraud in Kentucky
In early October, a Louisville psychiatrist became the latest Kentucky provider to plead guilty to health care fraud. The case was part of an unlawful kickbacks-for-referrals scheme to a now-defunct drug testing lab in Pennsylvania, and a simple illustration of a significant and all-too-common problem for Medicaid programs across the country. When Medicaid fraud of all kinds occurs, patients and taxpayers suffer.
According to the National Health Care Anti-Fraud Association, it’s an actuarial, statistical certainty that 3-10% of all Medicare/Medicaid dollars are lost to fraud. Using the most conservative 3% figure, KY’s $14 billion dollar Medicaid budget loses $390 million per year.
However, the Kentucky’s Medicaid Fraud Control Unit is fighting back. In 2019, there were 165 investigations, 22 indicted or charged, 17 convictions, 17 settlements/judgments, and recoveries of $26,333,549. In 2020, there were 210 investigations, 5 indicted or charged, 8 convictions, 165 civil settlements/judgments and recoveries of $32,965,744.
Insurers help fight fraud through a variety of tactics, including prior authorization, which provides critical safeguards that help prevent harm, lower costs, and promote appropriate use of medication and services. The deterrent effect of prior authorization is an important check, helping to dissuade bad actors from initiating fraudulent activities or identifying and investigating suspicious activity as it happens.
Examples of healthcare fraud committed by providers include:
· Double billing
· Billing non-covered services as covered services
· Billing for services that were not provided
· Providing and billing for services that were not needed
· Unnecessary prescriptions
· Accepting kickbacks and bribes
Consumers or healthcare users may commit healthcare fraud by:
· Falsifying information.
· Prescription forgery or selling prescription drugs
· Adding ineligible dependents to a medical plan
· Using someone else’s health insurance card
· Identity theft for healthcare purposes
Tips to protect yourself (courtesy of NHCAA):
Protect your health insurance ID card like you would a credit card. In the wrong hands, a health insurance card is a license to steal. Don’t give out policy numbers to door-to-door salespeople, telephone solicitors or over the Internet. Be careful about disclosing your insurance information and if you lose your insurance ID card, report it to your insurance company immediately.
Report fraud. Call your insurance company immediately if you suspect you may be a victim of health insurance fraud. Most insurers now offer the ability to report suspected fraud online through their website.
Be informed. Be knowledgeable about and aware of the health care services you receive, keep good records of your medical care, and closely review all medical bills you receive.
Read your policy and benefits statements. Read your policy, Explanation of Benefits (EOB) statements and any paperwork you receive from your insurance company. Make sure you actually received the treatments for which your insurance was charged, and question suspicious expenses. Are the dates of service documented on the forms correct? Were the services identified and billed for performed?
Beware of “free” offers. Is it too good to be true? Offers of free health care services, tests or treatments are often fraud schemes designed to bill you and your insurance company illegally for thousands of dollars of treatments you never received.
How to Report Medicaid Fraud
Kentuckians can report Medicaid fraud to the office of the Attorney General here.
or
Cabinet for Health and Family Services
Office of the Inspector General
Division of Audits and Investigations
275 E. Main St. 5E-D
Frankfort, KY 40621
Toll Free: (800) 372-2970
Monday through Friday, 8:00 a.m. - 4:30 p.m.