Revision 06-1; Effective April 10, 2006

 

8100 Provider Fraud and Abuse

Revision 06-1; Effective April 10, 2006

 

The Department of Aging and Disability Services (DADS) identifies, investigates and refers cases of suspected fraud or abuse of Medicare, Medicaid or social services programs.

When a provider commits fraud or abuse, DADS may take action against the provider, including:

  • exclusion from program reimbursement;
  • suspension from the program;
  • referral to the Health and Human Services Commission (HHSC) for civil monetary penalties; and
  • debarment from Medicaid programs.

DADS refers suspected fraud and abuse to Medicaid Program Integrity at HHSC.

 

8110 What is Provider Fraud?

Revision 06-1; Effective April 10, 2006

 

The Department of Aging and Disability Services (DADS) believes that people who provide services are entitled to the same protection under the law. However, when there is an indication of fraud, the allegations must be investigated.

Fraud is the intentional misstatement or concealment by the provider, which may result in a payment from DADS. Some examples of provider fraud are:

  • practicing without a proper license or obtaining a license under false pretenses;
  • billing for services that were not provided;
  • billing for services provided by inappropriate persons;
  • filing false claims;
  • continuing inappropriate billing after provider education visits; and
  • using improper billing practices.

 

8120 What is Abuse?

Revision 06-1; Effective April 10, 2006

 

Abuse is provider practices that are inconsistent with sound fiscal, business or medical practices.

These inconsistent practices result in unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of health care or standards required by contract, statute, regulation or interpretations of a statue or regulation sent to the provider.

Some examples of provider abuse are:

  • providing services that are not medically necessary;
  • billing for services provided by inappropriate persons;
  • practicing without a proper license or obtaining a license under false pretenses; and
  • violating the contract or provider agreement.

 

8130 Reporting Fraud and Abuse

Revision 06-1; Effective April 10, 2006

 

The Medical Provider Sanctions section, Department of State Health Services, has established a toll-free hotline for reporting suspected cases of Medicaid fraud and abuse. The number is 1-800-252-8263 and is available daily. Individuals who suspect fraud or abuse of assistance benefits, including eligibility and provider services, are urged to use this toll-free service.