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10 issues that constitute Medicaid fraud

On Behalf of | Oct 16, 2023 | Criminal Defense

The last thing you’d want to happen as a West Virginia Medicaid provider is to face criminal charges for fraud. This is why it’s imperative to understand the laws that govern such matters. Can you name 10 issues that could cause you to face charges for Medicaid fraud? If not, by the end of this post, you’ll know more about the topic. 

You can also encounter serious legal problems if you face accusations of falsifying records or committing fraud when applying for Medicaid as a recipient. This is a felony crime. Conviction of insurance fraud in West Virginia is punishable by substantial fines and possible jail time. In fact, in some cases, you’d be at risk for up to 10 years behind bars.  

10 ways providers can commit Medicaid fraud 

If you face accusations for Medicaid fraud as a West Virginia provider, your case might involve one or more of the issues shown in the following list:  

  • Billing for unnecessary services or items on purpose 
  • Billing for items or service the patient did not receive 
  • Using multiple codes when you should use one global code 
  • Upcoding a provided service to a higher billing level 
  • Claiming reimbursement for someone who is not the eligible beneficiary 
  • Cooperating with a beneficiary to file a false claim 
  • Prescription fraud, such as writing an unnecessary prescription 
  • Receiving kickbacks for referrals 
  • Accepting multiple ID cards for the same beneficiary 
  • Billing an ineligible beneficiary 

It is possible that clerical errors or other issues may occur that create the appearance of fraud where none exists. Therefore, if you are dealing with accusations for such crimes, try to remain calm and seek legal support right away. 

If you are a beneficiary, these acts constitute Medicaid fraud 

If you have a Medicaid ID card, you cannot share it with anyone else. Doing so constitutes fraud. Receiving more of the same prescription from multiple doctors, selling your prescriptions on the street and other drug-related issues can land you in a heap of trouble with the law, as well. It is also illegal to accept payment from a physician for referring beneficiaries for services.  

Your reputation and career may be at risk 

Accusations of Medicaid fraud can quickly snowball into a personal and professional crisis, even if you did not commit a crime. As in any criminal case, you deserve the opportunity to refute the charges against you in court. There are often several viable defense options available. Determining which one best fits your situation may be the key to a positive outcome.