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61 FBI L. Enforcement Bull. 17 (1992)
Medicaid Fraud Control

handle is hein.journals/fbileb61 and id is 315 raw text is: crrrT ri Iv III III10 Medicaid Fraud Control By JIM TAYLOR Until recently, few people paid much attention to one of the most lucrative crimes inflicted on American soci- ety-health care fraud. It wasn't until investigations of this crime began to take place across the country that the criminal justice sys- tem realized how widespread and profitable this crime is. Today, ex- perts estimate that health care fraud costs taxpayers $50 to $80 billion a year. This article centers on the issue of Medicaid fraud and the various schemes used by those in the health care profession. It then covers the State of Tennessee's efforts to bring these criminals to justice and the problems encountered in Medicaid fraud investigations. FRAUD SCHEMES Health care fraud investigations typically center around six main schemes-upcoding, phantom bill- ing, billing for unnecessary ser- vices, double billing, unbundling, and giving or receiving kickbacks. Investigators should recognize that Medicaid providers often engage in several such schemes, even though investigations may begin with indi- cations of only one scam. Upcoding For the most part, upcoding oc- curs when health care providers bill for a more expensive service than the one they provide to the patient. However, upcoding can also come in the form of generic substitu- tions-filling a prescription with a less expensive generic drug, while billing Medicaid for the more ex- pensive form of the drug. Medical fraud investigators for Tennessee initiated one such case, Operation Rx, because of a perva- sive problem across the State with generic drugs being substituted for prescribed medicines. Investigators October 1992 / 17 II e M

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