"Investigating Medicaid Provider
Fraud, Physical Abuse & Criminal Neglect
in Facilities Licensed Under Medicaid.
Many of
your friends, neighbors, and family members
rely on Medicaid for their health care.
Unfortunately, fraud, physical abuse, and
criminal neglect by some Medicaid providers
continues. You can help put a stop to this.
Fraud drives up the cost of health care for
all of us. And we each have a moral
responsibility and, under Texas law, a legal
duty to report abuse. The Medicaid Fraud
Control Unit stands ready to investigate these
allegations and bring perpetrators to
justice."
Texas Attorney General
What is Medicaid?
Medicaid is a federal/state cost-sharing
program that provides health care to people
who are unable to pay for such care. The Texas
Medicaid program is run by the Health and
Human Services Commission.
There are more than 2 million Texans
eligible for Medicaid, and more than 33,000
active Medicaid providers. A provider is any
person, group of people, or health care
facility that supplies medical services to
Medicaid recipients. Providers can be medical
doctors, osteopathic doctors, dentists,
hospitals, nursing homes, clinics, pharmacies,
ambulance companies, and others.
What is the Medicaid Fraud Control Unit?
The Texas Medicaid Fraud Control Unit was
created in 1979 as a division of the Office of
the Attorney General. The Unit has three
principal responsibilities:
- investigating criminal fraud by Medicaid
providers;
- investigating physical abuse and
criminal neglect of patients in health care
facilities licensed by the Medicaid program,
including nursing homes and Texas Department
of Mental Health/Mental Retardation homes; and
- assisting local and federal authorities with
prosecution
The Unit does not look into fraud
committed by Medicaid recipients. The Texas
Department of Human Services is responsible
for those investigations.
Fraud in the Medicaid Program
These are examples of fraud investigated by
the Medicaid Fraud Control Unit:
- billing Medicaid for X-rays, blood
tests, and other procedures that were
never performed, or falsifying a patient's
diagnosis to justify unnecessary
tests;
- giving a patient a generic drug and
billing for the name-brand version of the
medication;
- giving a patient over-the-counter drugs
or goods and billing for the prescription
drug;
- billing Medicaid for care not given, for
care given to patients who have died or
who are no longer eligible, or for care
given to patients who have transferred to
another facility;
- transporting Medicaid patients by
ambulance when it is not medically
necessary;
- requiring vendors to "kick
back" part of the money they receive
for rendering services to Medicaid
patients (kickbacks may also include
vacations, merchandise, etc.);
- billing patients for services already
paid for by Medicaid.
Activities of this nature may violate
various federal and state criminal laws.
Those convicted of fraud may also lose
their status as Medicaid providers and
have their professional licenses revoked.
Abuse of Medicaid Patients
It is a sad fact that too many Medicaid
patients, especially the elderly, are
physically and sexually 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:
- cuts, black eyes, bruises and burns,
especially when the caregiver cannot
adequately explain how they happened
(burns or bruises in an unusual pattern
may indicate the use of cigarettes,
instruments, or similar items);
- patients' fear of being alone with
caregivers;
- reports of physical abuse, such as
slapping, hitting, kicking, and biting, or
of sexual abuse;
- physical signs of sexually transmitted
diseases or of injury to the genital
area;
- difficulty sitting or walking;
- pregnancy.
Drug diversion is another form of abuse,
since it deprives the patient of proper
medication. It may also defraud the Medicaid
system. Drug diversion includes:
- a health care worker throwing away a
patient's medication, selling it, or
keeping it for him/herself;
- a doctor selling prescriptions;
- a nurse ordering medication for patients
without a doctor's approval.
Reporting
Suspected Fraud and Abuse
If you have reason to believe that someone
is defrauding the Medicaid program or is
abusing a Medicaid recipient, contact the
Medicaid Fraud Control Unit at 512/463-2011.
You may reach the Unit by e-mail at mfcu@oag.state.tx.us, or by fax at
512/320-0974.
Failure to Report is 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 the abuse or neglect.
You can report the abuse or neglect to the
Texas Department of Human Services Long Term
Care Regulatory by calling 1-800-458-9858. You
can also contact a local or state law
enforcement agency.
Failure to report suspected abuse or
neglect is a Class A Misdemeanor. Texas Health
& Safety Code Section 242.
Contact Information
By Us Mail:
Office of the Attorney General
Medicaid Fraud
Control Unit /023
P.O. Box 12307 Austin, TX
78711-2307
By Telephone:
Medicaid Fraud Control Unit
512/463-2011
Main
agency switchboard
512/463-2100
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