The unfortunate reality is that Medicaid 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 Medicaid 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. Our Long Beach Medi-Cal attorneys can help you to recognize and avoid Medi-Cal services fraud.
What is considered Medi-Cal services fraud?
Medicaid fraud happens when someone intentionally misrepresents the truth in order to acquire unauthorized Medicaid benefits. Medi-Cal services fraud is not only committed by patients. Healthcare providers can be guilty of Medi-Cal services fraud, as well. Our Long Beach Medi-Cal attorneys are experienced in recognizing these types of issues.
Typical examples of Medi-Cal 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.
What you can do to avoid the appearance of Medi-Cal fraud
In order to avoid unknowingly committing fraud, there are a few things you should not do. First, do not contact your doctor to request a service that you don’t need. Likewise, don’t let anyone persuade you to see a doctor for care or services you don’t need.
Common examples of provider fraud
Medi-Cal fraud is not limited to the actions of the patient, but can also be committed by healthcare service providers. Here are some common examples of that type of Medi-Cal fraud:
- Billing for services not actually performed
- Billing duplicate times for the same service
- Falsifying a diagnosis
- Billing for a more costly service than performed
- Accepting kickbacks for patient referrals
- Billing for a covered service when a non-covered service was provided
- Ordering excessive or inappropriate tests
- Prescribing medication that is not medically necessary
There are a few ways you can recognize this type of fraud. When you receive services from your health care providers, keep a record of the dates and save the receipts and statements you receive. You can then compare the dates and services on your calendar with the statements you receive from Medicare to make sure they are accurate.
Claims against Walgreens for alleged improper Medi-Cal billing
An announcement was made last spring that Walgreens Co. had agreed to settle claims against it for alleged Medi-Cal fraud for nearly $10 million. It was alleged that Walgreens knowingly submitted claims to California’s Medi-Cal program for reimbursement without obtaining the required diagnosis or documentation to support those claims. The lawsuit was filed under the False Claims Act by a former Walgreens pharmacist and a pharmacy technician. As whistleblowers, these two individuals were able to bring this claims on behalf of the government for alleged fraud perpetrated on a government program, such as Medi-Cal.
Walgreens and Medi-Cal
Walgreens is one of the largest drugstore chains in the country. The company owns and operates nearly 630 stress California alone and serves Medi-Cal patients. Walgreens provides access to prescription medication for individuals receiving Medi-Cal benefits – typically low-income children and adults, pregnant, and disabled residents of California.
How Medi-Cal works with pharmacies
Medi-Cal partners with various pharmacies, including Walgreens, by allowing them to distribute prescription medication to Medi-Cal patients and subsequently bill the cost of those medications back to the government. In doing so, Medi-Cal has created a list of “Code 1” drugs that include certain restrictions for those medications. The partner pharmacies are then expected to confirm and certify that the Code 1 drugs are being ethically dispensed.
Medi-Cal will provide reimbursement for certain Code 1 drugs when they are being prescribed for their approved diagnoses. However, pharmacies are required to submit a request to the California Department of Health Care Services (DHCS) for approval of reimbursement for medications that are being dispensed for a reason other than its intended diagnosis. The whistleblowers in the case against Walgreens alleged that the drugstore knowingly submitted reimbursements to Medi-Cal for medications that were dispensed for unapproved diagnoses. This is considered fraud.
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