Medicaid fraud happens when someone intentionally misrepresents the truth in order to acquire unauthorized Medicaid benefits. As your Los Angeles Medi-Cal attorney knows, Medi-Cal services fraud is not only committed by patients. Healthcare providers can be guilty of Medi-Cal services fraud, as well. If you have not heard of the Medi-Cal black market, let our Los Angeles Medi-Cal planning attorneys explain.
What is considered Medi-Cal services fraud?
Medi-Cal fraud happens when someone intentionally misrepresents the truth in order to acquire unauthorized Medi-Cal benefits. As your Los Angeles Medi-Cal planning attorneys know, Medi-Cal services fraud is not only committed by patients. Healthcare providers can be guilty of Medi-Cal services fraud, as well.
What is the Medi-Cal Black Market?
The term “black market” typically refers to some type of illegal, “underground” sales transactions. There are various types of black markets. When it comes to Medi-Cal, the most common black market that exists is the buying and selling of beneficiary provider numbers. What makes it easy to get away with selling provider numbers is the fact that Medi-Cal does not provide beneficiaries with EOBs (explanation of benefits). In other words, it is simpler for criminals to bill for services not actually provided to patients because they are unlikely to ever know about it or report it.
Clinic participates in black market scheme
The unfortunate reality is that even Medi-Cal providers who operate above board can unintentionally become entangled in the black market. A clinic with an extensive number of Medi-Cal beneficiaries seeking care asked a pharmacy to fill prescriptions for patients and have the medications delivered directly to the clinic. The ruse was that the patients would pick up their prescriptions at the clinic. In reality, the clinic had stolen the provider numbers and DEA numbers from several physicians and used them to obtain the prescriptions. During an audit, it was determined that the clinic had not actually delivered the prescription medication but instead sold it on the black market. Both the pharmacy and the physicians were initially suspected of being involved in the fraudulent scheme.
Pharmacy participates in black market scam
In another example, a physician sent prescriptions to a pharmacy which added to the order expensive medications that could then be sold on the black market. While the pharmacy was investigated, it was initially thought that the physician participated in fraud. Unfortunately, the physician had a difficult time proving he was unaware of the fraudulent scheme.
Durable Medical Equipment company colludes with clinic manager
A new physician fresh out of his residency worked at a clinic. Unsuspectingly, the clinic manager ordered wheelchairs and other durable medical equipment under the physician’s name. The equipment was never given to patients but was instead sold at the black market. The durable medical equipment company was in cahoots with the clinic manager. Again, the physician had to prove that he was not involved.
Typical examples of Medi-Cal services fraud by patients
Patient fraud can take many forms. For instance, it is fraudulent to file a claim for services or products that are not actually received by the patient. Similarly, forging or altering receipts in order to be reimbursed by Medi-Cal is also fraud.
Obtaining medications or products that are not needed and then selling them on the black market is an egregious form of fraud. If a patient provides false information or uses someone else’s insurance to obtain services to which they are not entitled, that is also actionable fraud. Another very common type of patient fraud is “shopping” for doctors in order to obtain multiple prescriptions.
The unfortunate reality is that Medi-Cal fraud and abuse exists. It costs billions every year in diverted funds that could have been used for valid health care services. Because of this fraud and abuse, the cost of Medi-Cal has increased needlessly. Another problem is the risk of harm to patients who are unknowingly exposed to unnecessary medical procedures for the benefit of fraudulent doctors. Your Los Angeles Medi-Cal planning attorney can help you to recognize and avoid Medi-Cal services fraud.
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