Medicaid fraud is on the rise, as are efforts by both state and federal officials to combat fraud. Medicaid is a federal program administered by the states. Each state has authority – within certain federal mandates – on how to provide and then enforce the regulatory and billing provisions within the state with regard to this program.
The same is true in North Carolina, where the enforcement of Medicaid fraud claims is usually done through the North Carolina Department of Justice.
Medicare – the program that provides health care to senior citizens – is administered through the Federal Government. Unlike Medicaid (a health care program for the poor), Medicare fraud is generally policed by the United States Department of Justice, although the Centers for Medicare and Medicaid Services (CMS) generally awards contracts to private contractors who are tasked with uncovering fraud and abuse.
Medicare or Medicaid fraud can generally be termed “Disability Fraud” since the object of the fraud is for either the sick person or another person or entity to receive either higher payments for services rendered or to receive payment even when no services were rendered.
(Disability fraud can also occur when someone files a false medical or disability claim with a private insurance provider.)
Many fraud investigations, particularly against larger corporations, result in settlements where the corporation agrees to pay back the government in exchange for the satisfaction of all claims, and in exchange for the government not criminally prosecuting executives.
For instance, the Department of Justice reported that it settled approximately $3 billion in claims against pharmaceutical companies for various kinds of fraud related to government benefits programs such as Medicare, Medicaid and the like.
North Carolina periodically conducts Medicaid fraud sweeps, the most recent of which has resulted in criminal charges against 18 people, including a Guilford County man for allegedly defrauding Medicaid out of $200,000.