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Med­ic­aid Fraud Con­trol Unit

What is the Medicaid Fraud Control Unit?

The Texas Medicaid Fraud Control Unit was created in 1979 as a division of the Office of the Attorney General. The unit has three principal responsibilities:

  • Investigate criminal fraud by Medicaid providers
  • Investigate abuse and neglect of patients in health care facilities funded by the Medicaid program, including nursing homes and Texas Department of Aging and Disability Services homes
  • Help local and federal authorities with prosecution.

Types of Medicaid Fraud

A few examples of Medicaid fraud:

  • A doctor billing Medicaid for X-rays, blood tests and other procedures that were never performed, or falsifying a patient’s diagnosis to justify unnecessary tests 
  • An ambulance company transporting Medicaid patients by ambulance when the patients can walk on their own and an ambulance is not medically necessary 
  • A nursing home bookkeeper writing and cashing checks for herself from residents’ trust fund accounts set up to take care of the residents’ expenses
  • A pharmacist giving a Medicaid customer a generic drug and billing instead for the name brand version of the medication
  • A home health agency billing Medicaid for care not given, for care given to patients who have died or who are no longer eligible, or for care given to patients who have transferred to another provider
  • An orthodontist billing Medicaid for braces that were never applied
  • A health clinic billing patients for services already paid for by Medicaid.

Signs of Abuse of Medicaid Patients

It is a sad fact that too many Medicaid patients, especially the elderly, are physically abused or neglected by some health care providers. In many cases, an abused person is completely dependent on the abuser and is afraid to complain. There are warning signs of physical abuse, sexual abuse and criminal neglect: Cuts, black eyes, bruises and burns, especially when the caregiver cannot adequately explain how they happened (burns or bruises in an unusual pattern may indicate the use of cigarettes, instruments or similar items);

  • Patients fear being alone with caregivers;
  • Reports of physical abuse such as slapping, hitting, kicking, biting or of sexual abuse;
  • Physical signs of sexually transmitted diseases or of injury to the genital area;
  • Difficulty sitting or walking; * Pregnancy.

Drug theft is another form abuse since it deprives the patient of proper medication. Drug theft includes:

  • A health care worker stealing a patient’s medication, selling it or keeping it for him/herself
  • A doctor selling prescription’s
  • A nurse order medication for patients without doctor’s approval
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