Medicaid Fraud Control Unit

Medicaid is a joint Federal and State program, authorized and funded under Title XIX of the Social Security Act that provides medical care to people with low incomes and limited resources. Though the federal government establishes general guidelines for the Medicaid program, each state establishes its own program, including eligibility criteria. The Oklahoma Medicaid Program is administered through the Oklahoma Health Care Authority.

Medicaid fraud occurs in several forms but is generally when a contracted Medicaid provider knowingly makes, or causes to be made, a false or misleading statement or representation for use in obtaining reimbursement from the Medicaid program. Fraud also occurs when a provider makes or accepts a kickback in exchange for providing services, attempts to charge recipients in excess of the Medicaid rates established by the Oklahoma Health Care Authority or fails to maintain records for services provided.

Typical schemes by which individuals and corporations steal from the Medicaid program include:

• Billing for services not rendered
• Billing for medically unnecessary services
• Upcoding (billing Medicaid for more expensive procedures than those that are actually performed)
• Double-billing (billing both Medicaid and a private insurance company or the recipient directly, or multiple providers billing Medicaid for the same recipient for the same procedure on the same date)
• Kickbacks (hidden financial arrangements between providers involving some material benefit in return for another provider prescribing or using their product or services, which frequently results in unnecessary treatment)

First, what is a Caretaker?

"Caretaker" means a person who has:

1.  the responsibility for the care of a vulnerable adult or the financial management of the resources of a vulnerable adult as a result of a family relationship;
2. assumed the responsibility for the care of a vulnerable adult voluntarily, by contract or as a result of the ties of friendship; or
3. been appointed a guardian, limited guardian or conservator pursuant to the Oklahoma guardianship and conservatorship. 

Patient abuse or neglect occurs when a person or caregiver knowingly causes physical harm to a resident of a health care facility or fails to give a resident needed medical services.

What is Neglect?

Neglect occurs when there is a failure to provide protection for a vulnerable adult who is unable to protect his or her own interest; failure to provide a vulnerable adult with adequate shelter, nutrition, health care, or clothing, or acts or omissions that result in harm or the unreasonable risk of harm to a vulnerable adult through the action, inaction, or lack of supervision by a caretaker providing direct services.

What is Abuse?

Abuse occurs when an individual causes or permits either the infliction of physical pain, injury, sexual abuse, sexual exploitation, unreasonable restraint or confinement, or mental anguish or the deprivation of nutrition, clothing, shelter, health care, or other care or services without which serious physical or mental injury is likely to occur to a vulnerable adult by a caretaker or other person providing services to a vulnerable adult.

What is Exploitation?

Exploitation is an unjust or improper use of the resources of a vulnerable adult for the profit or advantage, pecuniary or otherwise, of a person other than the vulnerable adult through the use of undue influence, coercion, harassment, duress, deception, false representation or false pretense.

The Medicaid Fraud Control Unit investigates instances of abuse neglect and exploitation of residents in long term board and care facilities and prosecutes those providers that would injure or exploit these vulnerable Oklahoma citizens.