In Texas, a healthcare business has many issues to navigate whether it is a group practice, a hospice, a therapy center, medical specialists, or any other entity. These businesses will rely on assisting patients who are covered by Medicaid. Because Medicaid comes from the government, it is not uncommon for treatment protocol to be scrutinized and for providers to be accused of fraud.
Even if a medical services provider has been aboveboard in its practices and adheres to the rules, they can be confronted with an investigation by the Texas Medicaid Fraud Control Unit. Regardless of whether the provider has comprehensive records and proof that it has charged patients according to the law, they must still be prepared for the investigation, know how to lodge a defense, and avoid the long-term challenges from a Medicaid fraud case.
Understanding Medicaid fraud and potential defenses
There are many ways in which a provider can commit Medicaid fraud. If the doctor claimed to have performed procedures or given tests to a patient but did not and charged Medicaid for it with falsified records, it would be a form of fraud. Some providers might send a bill to a patient who was already covered by Medicaid in the hopes that the patient will not realize their treatment was covered. In this way, the provider will be paid twice.
The provider could give a patient a service that is costlier than what they received or one they did not need. Coding is a common way in which fraud is committed. The provider might bill Medicaid for separate procedures that are expected to be placed under a single code. Kickbacks could include getting paid for referring patients to another medical professional so they can receive payments from Medicaid. Perhaps the other provider is paying cash to the referring provider so they can both profit.
Even if there is an investigation accusing a medical business of Medicaid fraud, it does not necessarily mean they will be found to have violated the law. There are effective defenses. Perhaps the medical provider showed that the alleged fraud was a simple mistake such as an error made by an employee and was not a willful attempt to defraud Medicaid.
It can be helpful to have documentation of compliance. That can include a comprehensive program to train employees at the facility in the proper way to bill Medicaid and treat patients.
Make sure to lodge a full defense against Medicaid fraud accusations
Healthcare providers who are trying to build or maintain a business can see their efforts undone by accusations of Medicare and Medicaid fraud. This is especially challenging given the new rules that are being implemented by the government and more intense analysis of how Medicaid is being charged for its services.
The government is vigilant in trying to find, investigate and prosecute this type of fraud. Simply because there is an investigation does not mean that the medical provider is guilty. Even if there were mistakes in charging Medicaid, it does not need to be a long-term problem. There are options to address the issue and move forward.
For these cases, it is imperative for the medical services provider to know the law, understand what they are accused of, gather the evidence, and to have professional guidance to fight the charges. They can protect their business and avoid disfavor with the government, overseeing entities in the state, and the community.