Criminal Justice

Criminal Medicaid Fraud

Medicaid is a federal/state cost-sharing program that provides health care to people who are unable to pay for such care. In Texas, the Medicaid program is administered by the Texas Health and Human Services Commission.

More than 3.7 million Texans are eligible for Medicaid, and there are more than 57,000 active Medicaid providers. A provider can be any person, group of people, or health care facility that supplies medical services to Medicaid recipients. Providers include doctors, medical equipment companies, podiatrists, dentists, licensed professional counselors, hospitals, adult day care centers, nursing homes, clinics, pharmacies, ambulance companies, case management centers and others.

What is Medicaid Fraud

These are examples of fraud:

Activities of this nature violate federal and state criminal laws and can result in significant fines and/or incarceration. Those convicted of fraud may also lose their status as Medicaid providers.

The Medicaid Fraud Control Unit

The Texas Medicaid Fraud Control Unit (MFCU) was created in 1979 as a division of the Office of the Attorney General. The Attorney General’s Medicaid Fraud Control Unit stands ready to investigate these allegations and bring perpetrators to justice.

The unit has four principal responsibilities:

MFCU does not look into fraud committed by Medicaid recipients. The Texas Health and Human Services Commission Office of Inspector General is responsible for investigating Medicaid recipient fraud.

Abuse of Medicaid Patients

It is a sad fact that too many Medicaid patients, especially the elderly, are physically abused or neglected by some health care providers. In many cases, an abused person is totally dependent on the abuser and is afraid to complain.

These are some of the warning signs of physical abuse, sexual abuse and criminal neglect:

Drug diversion is another form of abuse. It is the simple theft of drugs that deprives a patient of proper medication. Drug diversion includes:

Reporting Suspected Fraud or Abuse

If you have a reason to believe that someone is defrauding the Medicaid program or is abusing a Medicaid recipient, contact the Medicaid Fraud Control Unit headquarters in Austin or one of the field offices.

You can also report the abuse or neglect to the Texas Department of Aging and Disability Services by calling (800) 458-9858. You can also contact local or state law enforcement.

A CRIMINAL OFFENSE: If you own or work in a nursing home or other facility and believe that a resident has been or may be the victim of abuse or neglect, you must report it. Failure to report suspected abuse or neglect is a Class A misdemeanor (Texas Health & Safety Code Section 242.122).

MEDICAID FRAUD DRIVES UP THE COST OF HEALTH CARE FOR ALL OF US. We each have a moral responsibility and a legal duty under Texas law to report Medicaid fraud.