Medicaid Fraud by Health Service Providers

WHAT IS MEDICAID FRAUD BY HEALTH SERVICES PROVIDERS?

Medicaid pays for the medical expenses of many Puerto Rican residents who cannot afford a medical plan.

Unfortunately, there are unscrupulous health service providers that sometimes steal money from Medicaid. Providers including doctors, dentists, and hospitals can:

• Charge for services that were never provided.
• Charge more for services that were provided.
• Charge for exams, services and products that are unnecessary.

DOES MEDICAID FRAUD AFFECT ME?

Medicaid fraud affects everyone!

The more unscrupulous providers they steal, Medicaid will have less money available for the poor who need it. Some may be excluded from the program. Others may suffer the loss of available services. Patients treated by fraudulent providers may face more problems due to inappropriate medical treatment.

In reality, all residents of Puerto Rico taxpayers pay the cost of this crime. Puerto Rico has to cover fraud losses by reducing other government services and raising contributions.

COMMON FORMS OF SUSTAINABLE FRAUD AND ACTIVITY AGAINST MEDICAID

• Billing patients who do not exist or patients from other providers.
• Billing for services that were not provided.
• Billing for used medical equipment as if it were new.
• Billing for unnecessary treatments and exams.
• Billing for medical services that are actually provided by unauthorized personnel.
• Accept bribes.
• Have a patient pay more than a Medicaid-approved copayment for services received.
• To deliberately and voluntarily request or receive payments of clandestine commissions or bribes in exchange for referring Medicare or Medicaid patients.
• A doctor who deliberately and voluntarily sends a Medicare or Medicaid patient to health care centers with which he or she has a financial relationship (Stark Law).
• Billing balance: ask a patient to pay the difference between discounted or negotiated rates, and the provider's usual and normal rates.

HOW TO DETECT A FRAUD AGAINST MEDICAID BY A HEALTH SERVICES PROVIDER?

• If you receive an Explanation of Benefits (EOB) from your Vital Plan Insurance Company, read it carefully and notify the Medicaid Integrity Program that you did not receive the detailed services.
• If a provider suggests treatments or services and you believe they are not necessary, be cautious of the recommendation. Ask for a second opinion.

WHAT TO DO IF YOU SUSPECT FRAUD AGAINST MEDICAID BY A HEALTH SERVICES PROVIDER?

If you suspect fraud, call the Medicaid Integrity Program (787) 765-2929 Exts. 6756 or write to prmedicaidintegrity@salud.pr.gov.

All information you provide to us will be handled confidentially.