Pennsylvania Steps Up Fight on Medicaid Fraud

Because Medicaid fraud significantly increases healthcare costs, Pennsylvania is stepping up investigation and prosecution of Medicaid fraud. According to a recent news story, in one year, false claims against Medicaid cost Pennsylvania taxpayers over $117 million from an annual budget of $4.5 billion.

Of Pennsylvania’s more than 50,000 healthcare providers who participate in the state Medicaid program and service over 1.5 million Medicaid beneficiaries, a small percentage enrich themselves at the expense of the system — and consequently at the expense of Pennsylvania taxpayers. Medicaid fraud includes activities such as billing for services not actually performed, misrepresenting services, filing false cost reports, paying kickbacks, performing medically unnecessary services and providing substandard care.

One of the proposals for cutting down on fraud is to have the Medicaid program provide explanation of benefit statements when claims are made. While sending the statements would be a significant expense, the hope is that Medicaid beneficiaries would report when claims were made for services that they had not received or when services were misrepresented.

Of the $117 million in fraudulent payments that Pennsylvania has recovered since 2010, more than $100 million of that total was from a number of drug companies who manipulated reports of wholesale prices to maximize their Medicaid payments.

Medicaid recipients have also been involved in fraud and have been the subject of Pennsylvania’s Office of Inspector General (OIG) investigations and prosecutions. Pennsylvania has recovered a total of about $100,000 from Medicaid beneficiaries who engage in fraud.

OIG investigations are also credited with saving Medicaid from paying approximately $28 million in fraudulent claims.

Waters & Kraus is a national firm with highly skilled lawyers practicing qui tam litigation in four offices, including Dallas, Los Angeles, San Francisco, and Baltimore. Our attorneys have decades of experience successfully representing whistleblowers in a variety of fraud cases. Contact us or call our attorneys at 800.226.9880 to learn more about our practice and how we can assist.

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