Investigation Reveals the Large Number of Health Care Providers Revoked From Medicare But Still Billing Medicaid

Monday, May 18, 2015
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by the Florida Bar in Health Law
Medicaid fraud and abuse continues to cost states billions of dollars every year. The U.S. Attorney General's office has estimated that up to 20 percent of Medicaid billing is fraudulent and costs the U.S. Treasury between $60 and $90 billion per year. Doctors add fuel to the fire by submitting false claims for patient care, like the Georgia optometrist who claimed he conducted 177 eye exams in one day.

There is also an issue of doctors who have been terminated as Medicare or Medicaid providers in one state but continue to bill Medicaid in another state. This problem is not new. In an effort to thwart fraud, the Affordable Care Act (ACA), implemented in 2010, enacted tougher provisions against Medicare and Medicaid fraud. The ACA explicitly requires that states suspend the billing privileges of providers who have been terminated or revoked by any state Medicaid Program or by the Federal Medicare Program. Requirements such as this are aimed at improving the integrity of the system and reducing fraud.

How Bad Is It?

The OIG of the U.S. Department of Health and Human Services (HHS) investigates fraud and abuse in Medicare, but some of the bad eggs continue to slip through the cracks. For example, an analysis of state and federal data by Reuters found that more than one in five of the health care providers prohibited from billing Medicare, are still billing state Medicaid programs. Overall, Reuters discovered 1,800 banned health care providers that were still able to bill Medicaid in 2014.

Medicaid Integrity Provisions in the ACA.

In an effort to reduce fraud and abuse, an amendment to the ACA implemented the following additional provisions in 2013:  
-   Create a web based portal that enables states to compare information on providers who have been terminated. States are required to enter information about the providers into the database.

-    Increase provider screening and enrollment requirements. Screenings include license verifications, database checks, unscheduled medical site visits, fingerprinting and criminal background checks.
-    Require states suspend payments to individuals or entities where there is a credible allegation of fraud.

-    Allow states to impose temporary bans to prevent fraud among new health care providers.

-    Require state Medicaid programs to establish Recovery Audit Contractor (RAC) programs to identify and recover overpayments and underpayments.
-    Mandate the use of the Nation Correct Coding Initiative (NCCI), to minimize improper coding.

-    Encourage data system enhancements and expand Medicaid Management Information Systems (MMIS) data elements to identify fraud.
-    Require that physicians document a face-to-face encounter with a Medicaid beneficiary before ordering home health services, medical supplies and equipment ("F2F" provisions).

The Verdict.

Although the efforts to reduce Medicare and Medicaid fraud by state and federal agencies are significant, state Medicaid programs continue to pay thousands of health care providers who are deemed unsuitable to bill Medicare, potentially costing the U.S. taxpayers hundreds of millions of dollars that the ACA is attempting to save.


What do you think of these large crackdowns on Medicare and Medicaid fraud? Do you think they work as a deterrent for others committing health care fraud? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced in Handling Medicaid Audits, Investigations and other Legal Proceedings.

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Health Care Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), the FBI, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS). Often other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies participate. Don’t wait until it’s too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today. Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.

The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (ALFs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at


Shaw, Jazz. "Breathtaking Medicaid Fraud Case Snags 9 Doctors in New York City."
Hot Air. (April 2, 2015). From:

Pell, M.B., & Cooke, K. "Banned From Medicare, Still Billing Medicaid." Reuters. (April 29, 2015).

National Conference of State Legislatures. "Medicaid Fraud and Abuse." (April, 2013).

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

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"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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