Why Would Medicaid Fraud Investigate You?

Why Would Medicaid Investigate You?

Receiving a letter from the Human Resources Administration (HRA) indicates that either local or state government suspects that you are guilty of Medicaid fraud, and is not a matter to be taken lightly. A Medicaid Fraud conviction can result in serious legal consequences and therefore it is of utmost importance that you understand exactly what Medicaid fraud is if you ever happen to receive such a letter in the mail.

Why Would Medicaid Fraud Investigate You?

What is Medicaid Fraud?

Medicaid Fraud is the disclosure, misrepresentation or manipulation of information to receive Medical Health Care rewards; making unnecessary or prohibited referrals for certain health services is also considered Medicaid Fraud.

What are the Different Types of Medicaid Fraud?

There are various types of Medicaid Fraud that can potentially incarcerate both health service providers and beneficiaries. Some of the most common types of Medicaid fraud include:

Billing Misrepresentation

  • Billing for unnecessary services or items.
  • Billing for services or items not provided.
  • Billing multiple codes for services that could have been represented with one. universal code (unbundling.)
  • Billing for services that are more complex than the ones provided (upcoding.)
  • Billing for singular procedures multiple times (double billing.)
  • Knowingly billing for nonqualified beneficiaries.

Exploitation of Medicaid ID Cards

  • Beneficiary duplicates Medicaid ID card and sells copies.
  • Beneficiary shares Medicaid ID card with non-qualified Medicaid receivers to share benefits.
  • Provider knowingly treats someone with multiple ID cards and expects compensations.
  • Provider knowingly treats a non-qualified Medicaid recipient and expects compensations.

Drug Diversion

  • Provider attempts to write off unnecessary prescriptions in order to obtain them for personal use or profits.
  • Beneficiary alters prescription for personal use or profits.
  • Beneficiary attempts to receive the same prescription from multiple doctors.


  • Provider attempts to promote recipients to give referrals
  • Provider pays recipients to give referrals
  • Provider recommends an unnecessary referral
  • Beneficiary accepts providers rewards for referrals

Disclosing  Information to Qualify for Medicaid

  • Recipient attempts to disclose income information.
  • Recipient fails to inform the HRA about change in address, household members or income.

What To Do Once You Are Accused of Medicaid Fraud?

First and foremost, it is your legal right to remain silent. You do not have to say or do anything that could be used against you in the court of law, and most importantly, you will not lose your benefits for refusing to cooperate. Contact your Medicaid fraud attorney immediately and start building up a defense case. You need someone who understands Medicaid law to build a defense case for you since the early stages in your investigation can play a significant role in determining whether or not you are convicted. The investigation team has most likely built a case against you already by going through your records and interviewing witnesses so it is necessary that you start regaining control of the situation.

Possible Consequences If You Are Accused of Medicaid Fraud

Penalties can be as severe as five years to life in prison and fines can be as high as tens of thousands of dollars depending on the charges. Prohibition and restitution fees are also common among conviction penalties. Those convicted of fraud are mandated to return all stolen assets in addition to paying fines. Providers charged with Medicaid Fraud may also lose their license to practice.