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Medicaid Fraud Prevention: How to Protect the Integrity of the Program

Medicaid Fraud Prevention: How to Protect the Integrity of the Program

Medicaid fraud can affect healthcare providers, taxpayers, and patients. Everyone should be wary of this issue – whether you are familiar with Medicaid or you are new to the program. If you are not careful, you could receive treatments that are totally unnecessary – or even harmful. Patients should also be careful not to engage in any fraud themselves, as this behavior can lead to various consequences. What do you need to know about Medicaid fraud prevention? Can an elder law attorney help you with this issue?

What if I Was Accused of Medicaid Fraud?

If you are a patient and you have been accused of Medicaid fraud, you may not know where to begin. The most common form of patient Medicaid fraud is receiving benefits you are not eligible to receive. All patients should know that Medicaid is a program specifically designed for low-income individuals, disabled people, and similarly vulnerable Americans. If you abuse this system and pursue Medicaid benefits in a fraudulent manner, you could face serious consequences.

According to Health and Human Services, it is illegal to submit fraudulent applications to receive Medicaid. If you knowingly lie or misrepresent facts in your application, you could face serious consequences. That being said, there is a major difference between intentionally lying and simply making a mistake on your application.

Consequences may become even worse if you receive benefits for an extended period of time and the authorities eventually discover that your application was based on a lie. For example, you might claim to be physically disabled. If someone sees you lifting heavy weights at the gym, this could be an example of Medicaid fraud. Prison time is possible for lying on your Medicaid application. That said, the most common consequence is a financial fine. This fine is usually equivalent to the amount of money you fraudulently received from Medicaid.

Patients who conspire with healthcare providers to engage in Medicaid fraud also face serious criminal consequences. If a doctor asks you to lie or participate in a fraudulent scheme to steal money from the healthcare system, you should refuse. While you cannot be held liable for unwittingly participating in these schemes, active involvement could make you a co-conspirator.

Another common type of Medicaid fraud involves identity theft. If you claim to be someone else to receive Medicaid benefits, you may face serious criminal consequences.

Common Examples of Healthcare Provider Medicaid Fraud

The most common examples of Medicaid fraud are committed by healthcare providers. The False Claims Act prevents healthcare providers from defrauding the government with shoddy, overpriced, or non-existent medical services. If a doctor submits one of these fraudulent claims, they may face serious fines and the loss of their medical license.

There are also strict federal laws against kickbacks. The Anti-Kickback Statute prevents doctors from using patients to refer other Medicaid patients. If a doctor offers you money if you refer your friends or family to them, this is likely a violation of federal law. The reward does not have to be cash, and it may include hotel stays, food, and more.

Medical companies are also prohibited from offering doctors compensation for patient referrals. For example, the doctor might receive compensation if they prescribe you a specific type of medication.

Medicaid Fraud Can Seriously Harm Patients

Medicaid fraud doesn’t just enrich criminals – it can also harm patients. A common type of Medicaid fraud involves performing unnecessary treatments to increase payments. Often, these treatments are highly invasive and risky. Patients have lost their lives or suffered life-altering complications because doctors were too focused on defrauding the Medicaid system.

Doctors may also order unnecessary, expensive tests – despite you showing virtually no signs of a particular illness. In addition, healthcare providers may charge separately for treatments that are usually packaged together. This scheme is called “unbundling,” and it can dramatically increase costs.

Recent Examples of Medicaid Fraud

In December of 2024, 20 people in Pennsylvania were charged with Medicaid fraud. The charges involved a home care agency, and the defendants had allegedly sapped millions from the Medicaid program by submitting claims for treatments that were never provided.

In January of 2025, a man in New York pleaded guilty to Medicaid fraud after stealing $700,000 from the system. This individual was providing transport for patients, but he billed each patient for a separate trip – even when patients were transported together in one vehicle.

Also in January, a man in Minneapolis was charged with Medicaid fraud, having allegedly stolen over $7 million from the program by billing for services never provided. The company is accused of billing patients twice for the same services, billing for treatments provided by employers no longer working for the company, and more.

How Can We Fight Medicaid Fraud?

Medicaid and Medicare fraud cost taxpayers almost $150 billion per year. This issue is rampant, and it shows no sign of slowing down. Medicaid Fraud Control Units (MFCUs) help identify fraud – but these units are stretched thin. Inevitably, some healthcare providers and patients get away with Medicaid fraud each year.

From a patient’s perspective, the best approach is to be hypervigilant. If something does not seem right, consider going with a different healthcare provider. If possible, prioritize working with doctors who are cautious about prescribing treatments. If a doctor seems strangely enthusiastic about prescribing many tests, surgeries, and medications, this could be a sign they are defrauding the system. Good doctors always play it safe, and they prioritize the patient’s well-being above their own profit margins.

Can an Elder Law Attorney Help With Medicaid Fraud?

If you are encountering issues related to Medicaid fraud, consider speaking with an experienced elder law attorney for more information. These legal professionals can help those who have been harmed by Medicaid fraud. Lawyers may also help you avoid allegations of fraud if you are not sure how to navigate this system in a compliant manner. Whatever your situation might be, you are not alone. Contact The Elderly Care Law Firm today for further information.

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Sherrie Lim

Client Services Coordinator

Sherrie Ann Lim brings over twelve years of customer service experience and a strong background in team leadership and client support. Although she holds a Bachelor of Science degree in Physical Therapy, her career path led her to the dynamic world of the contact center industry, where she discovered a deep passion for service, communication, and operational excellence. 

Sherrie is known for her perseverance, enthusiasm, and confident sense of responsibility. She consistently delivers high-quality results, efficiently managing tasks while remaining flexible to the evolving needs of her clients. Her commitment to continuous improvement and excellence positions her as a trusted ally for businesses seeking proactive and reliable virtual support. 

Drawing from her college background, Sherrie has a deeper understanding of the physical and emotional needs associated with aging, making her especially attuned to the importance of compassionate and informed care for the elderly. She recognizes that elder care isn’t just about physical support, it also involves emotional presence, patience, and clear communication. Her strong appreciation for family ties fuels her commitment to helping clients manage the intricacies of elder care with empathy and attentiveness, ensuring that elderly loved ones feel respected, safe, and truly cared for. 

 

She loves taking care of her family during her rest days and free time, finding joy in the simple yet meaningful routines of home life. Whether it’s preparing home-cooked meals, baking sweet treats for her kids, or tackling household projects, Sherrie finds fulfillment in creating a nurturing and organized environment for her family. Whenever time and opportunity allow, she also enjoys traveling with her family, exploring new places, creating lasting memories, and embracing experiences that strengthen their bond and bring joy into their lives. 

Fun Fact: Sherrie’s two kids were born on the exact same date—two years apart! 

May Cruz

Client Services Coordinator

May began her community service career with the Philippine Department of Health as a Computer Operator, providing vital technical support to healthcare workers across island provinces and helping to bridge technology gaps in remote medical settings. Her commitment to service extended beyond her official duties—she also volunteered in medical missions, assisting indigenous communities and contributing to the delivery of essential healthcare with empathy and cultural sensitivity. 

Continuing her dedication to public service, May later worked at a law firm as a Disability Service Coordinator, assisting military veterans in navigating disability services. She brought empathy, compassion, and heart to the role, ensuring that each veteran felt heard, respected, and supported throughout the process. 

With a unique blend of technical expertise and human-centered care, May remains deeply committed to using her skills to uplift underserved and vulnerable communities. 

Fun Fact: Despite not knowing how to swim, May is a certified open water diver. Her adventurous spirit and determination push her beyond her comfort zone—both in life and under the sea.