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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: 








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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


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