Florida Dental Access Guide

Medicaid Fraud:What is it and How to Report it?

What is Medicaid Fraud?

Medicaid fraud is the intentional misrepresentation by a provider or Medicaid recipient with the knowledge that the fraudulent action would result in any type of unauthorized benefit for oneself or another individual.

Common Types of Fraud that can be Identified on a Billing Statement

Providers use a coding system to bill Medicaid for any services rendered to Medicaid recipients. Upcoding occurs when a provider bills for a more excessive service than the one actually performed. For example, if a patient sees a health care provider for ten minutes on a simple matter and the provider bills for an hour-long, complex visit, that is upcoding.

Certain billing codes account for more than one service, also known as bundling. Unbundling occurs when a provider bills each stage of a procedure as if it were a separate procedure increasing reimbursement from Medicaid. For example, if a provider charger not just for the tooth extraction but also for incision, drainage and suturing separately, that is unbundling.

Common Examples of Fraud Commited by Providers

1

Billing for services that weren’t provided.

2

Billing for services or items the patient no longer needs.

3

Billing multiple times for the same service.

4

Up charging for equipment and services.

5

Creating and reporting false claims.

6

Ordering and billing for services that a recipient doesn’t qualify for or need.

7

Utilizing fraudulent licenses or certifications.

8

Providers accepting multiple Medicaid ID cards to increase the reimbursement rate.

Preventing Fraud

(Click on the pulsing dots to see anti-fraud suggestions)

Do not share your personal information or Medicaid ID with anyone except your trusted providers.
Be aware of anyone offering you money, gifts, or low-cost care in exchanged for your Medicaid information.
Be aware of what is included in your coverage plan and always review your explanation of Medicaid benefits for accuracy paying close attention for services and dates listed verifying that you in fact received those services.
Do not ask your provider for dental care you do not need.
Ask questions if someone wants you to have services that you feel you do not need.

How to Report Medicaid Fraud

The Office of Medicaid Program Integrity of the Inspector General at the Agency for Health Care Administration.
  • Call: 1-888-419-3456
  • Fill out this online form
The Office of Attorney General
For more information about Medicaid fraud and for ways to report Medicaid fraud please visit the following page.
MORE INFORMATION

The information provided on this webpage was retrieved from the Office of Inspector General at the Agency of Health Care Administration on May 15, 2023.

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