Five Top Reasons for Medicaid Fraud Investigation

Medicaid is a federal and state health coverage program that provides health care to people who are unable to pay for it themselves. It is offered free of charge to certain individuals and families, granted that they meet the eligibility requirements. There are usually two parties who are involved with receiving Medicaid: recipients and providers. Recipients pertain to individuals or families who are receiving Medicaid benefits. Providers pertain to individuals or companies that are paid by the Medicaid program, including doctors, dentists, pharmacies, clinics, hospitals, etc. Usually, Medicaid Fraud investigations for either party occur when the investigator suspects that you have been lying or failed to disclose important information. The top reasons behind Medicaid Fraud investigations against recipients include but are not limited to:


  1. Falsification of information

The eligibility requirements for the Medicaid program are strict. If you lie or provide false information that does not match records and documents, it is likely that you will be targeted by investigators.

  1. Failing to disclose important information regarding income and/or assets

Attempting to hide any information will also raise an issue with investigators. You can’t lie or hide documented information.

  1. Failing to update the program on any changes regarding income/assets/relevant eligibility circumstances

Any changes that are related to Medicaid eligibility should be reported to the agency immediately or else it will be considered fraud. Changes in income, living situation, or any information that is considered by the program should be reported.

  1. Abuse of Benefits

Some examples of abusing Medicaid benefits include: altering, forging, obtaining duplicate prescriptions, re-selling medicine, or products obtained through the program, and more.

  1. Cheating with Medicaid cards

If you allow another person to use your Medicaid card or use more than one Medicaid card, you are committing fraud. The top reasons behind Medicaid Fraud investigations against providers include but are not limited to:

A. Cheating the billing system

Ultimately, this is one of the most common issues that usually result in Medicaid fraud because there are numerous ways that providers cheat the billing system. Billing for services not provided, billing for fake or non-existent medical conditions, billing for services that were not medically necessary, and other scenarios all fall under this common reason for Medicaid Fraud investigation.

B. Misrepresentation of provided services

Some examples include billing for more expensive services than actually rendered, billing twice for the same service, billing separately for services that should be billed together, dispensing generic drugs while billing for more expensive brand-name drugs.

C. Falsifying information

This includes submitting false time records, signatures, or price reports, prescribing or filling fraudulent prescriptions, and more.

D. Bribery

Some providers may choose to give or receive something in return for medical services or referrals.

E. Violation of Medicaid rules

This includes: billing for services provided by unlicensed or uncertified personnel, billing for services provided by someone on a Medicaid exclusion list, and more. Regardless of whichever party you pertain to or the reasons for investigation against you, do not try to handle this situation on your own. By the time you receive notice of Medicaid Fraud investigation, the investigator has gathered evidence against you and you will likely need the assistance of an attorney.

Contact an experienced Medicaid Fraud Attorney immediately. Attorney Inna Fershteyn has years of experience regarding Medicaid Fraud investigations and can help you by negotiating a settlement that reduces or eliminates penalties and interest – and most importantly —  by negotiating an agreement that your case will not be referred for criminal prosecution. To arrange a confidential consultation, call at (718) 333-2394 or ask your questions at