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  • Medicaid Fraud Charges

Dallas Fraud Defense Attorneys

Medicaid is a nationwide program that is described as a cost-sharing project that provides healthcare to individuals who are unable to pay for it. The state of Texas Medicaid program is administered by the Texas Health and Human Services Commission. The Texas Health and Human Services Commission oversees and establishes:

  • Eligibility Standards;
  • The type, amount, duration, and scope of services; and
  • Rate of payment for services.

Texas Medicaid Providers

Currently, in the state of Texas, over 3.5 million people are eligible to receive Medicaid benefits. At this time, there are approximately 57,000 active suppliers of Medicaid. A provider of Medicaid may be any person, group of people, or healthcare facility that provides medical services to Medicaid beneficiaries. Providers include, but are not limited to: doctors, dentists, professional counselors, nursing homes, and pharmacies.

Each state is allowed to determine what its Medicaid coverage will ultimately provide, however the Federal Government has set some mandatory requirements for each state:

  • Inpatient and outpatient hospital services;
  • Prenatal care;
  • Child vaccines;
  • Nursing facility services for individuals 21 years of age or older;
  • Physician services;
  • Rural health clinic services;
  • Home health care;
  • Laboratory and X-ray services;
  • Nurse-midwife services;
  • Ambulance services; and
  • Early and periodic screening, diagnostic, and treatment services for children under the age of 21.

Along with what is required for a state’s Medicaid plan, a state may also utilize additional services. There are over 30 federally approved services that a state may include in its Medicaid coverage. Some include:

  • Diagnostic services;
  • Prescribed drugs;
  • Optometrist services; and
  • Rehabilitation and physical therapy services.

Who in Texas is Covered under Medicaid?

Generally, Medicaid is available to individuals in the state with low incomes. In addition to income level, there may be additional guidelines that a state has incorporated in order to determine which citizens are eligible for the service. However, similar to included services, the Federal Government generally mandates that every state must provide coverage to individuals who receive federally assisted income-maintenance payments and similar individuals who currently do not collect cash payments.

These federally required individuals typically include:

  • Children under the age of six years old whose family income is at or below 133% of the Federal Poverty Level;
  • Pregnant women with family income below 133% of the Federal Poverty Level;
  • Supplemental Security Income (SSI) recipients; and
  • Special protected groups. For example, individuals who have lost cash assistance because of earnings from work or from increased Social Security benefits.

Medicaid Fraud in Texas

There are various ways one can be charged with Medicaid fraud. Typically, it involves a provider being untruthful with services provided. Some examples of Medicaid fraud include:

  • Provider bills Medicaid for X-rays, blood tests, and other procedures that were never performed or falsifying an individual’s diagnosis to explain unnecessary tests;
  • Provider gives an individual a generic drug, but bills Medicaid for the name-brand version of the drug;
  • Provider bills Medicaid for care that was never given to an individual; and
  • Provider bills individuals for services that have already been paid by Medicaid.

New Texas Laws Hope to Stop Medicaid Fraud

In July of 2013, the state of Texas passed a handful of new laws implemented to curb Medicaid fraud and abuse. The focus of these new laws were concentrated on four areas:

  1. Texas expanded its previous definition of “unlawful act.” The new law expands the definition of conspiracy and incorporates a reverse false claim element in the updated statute.
  2. Next, the state chose to employ a more explicit statute of limitations. Specifically, when a case comes up in which Texas decides not to intervene, a whistleblower is able to recover illegally obtained monies for up to six years before the suit was filed, or three years from the date Texas knew or should have known material facts included in the violation, but never more than ten years before the suit was originally filed.
  3. Texas now requires dismissal of any publicly disclosed claims. The updated statute requires courts to dismiss those claims that have been publicly disclosed in the state or federal criminal or civil hearings, in state legislative or administrative reports, other state hearings, audits or investigations, or by a news source, unless when the whistleblower qualifies as an “original source.” The law defines “original source” as a person who “has knowledge that is independent of and materially adds to the publicly disclosed allegation.”
  4. Lastly, these updates call for an expansion of the current anti-retaliation provisions. This means that whistleblowers are now sheltered from discrimination that is based on the whistleblower’s actions to investigate and/or report Medicaid fraud. There is now a three-year statute of limitations for any retaliation claims.

The state legislature hoped that the adoption of these four updates in the law would allow an increased allocation of resources to investigate potential Medicaid fraud. Additionally, it also wanted to work towards restricting a provider’s ability to market services specifically to Medicaid patients.

Since 1979, Texas has utilized an agency known as the Texas Medicaid Fraud Control Unit (TMFCU). This unit concerns itself with provider fraud only. This unit is associated with the Office of the Attorney General and has four main duties:

  1. To investigate criminal and civil fraud perpetrated by Medicaid providers;
  2. To investigate physical abuse and criminal neglect of patients in licensed Medicaid health care facilities;
  3. To prosecute criminal fraud by Medicaid providers or aid any local or federal authorities with a prosecution; and
  4. To investigate fraud within the Medicaid administration program.

Recipient Fraud in TX

An individual in Texas may be charged with Medicaid recipient fraud for knowingly submitting false or fraudulent claims to the state’s Medicaid program. Individuals may also face penalties for paying or taking bribes in exchange for referrals and/or ordering supplies.

Penalties for Medicaid Fraud in the State of Texas

Felony charges of Medicaid fraud in Texas can lead to penalties including up to five years in prison and a fine for as much as $250,000 for an individual and as much as $500,000 for a corporation.

If the Medicaid fraud charge is considered to be a misdemeanor, an individual faces a fine for as much as $100,000 and a corporation may face up to $200,000.

Call The Wilder Firm in Dallas today!

If you have been arrested and are facing charges related to Medicaid fraud, contact an experienced attorney at The Wilder Firm. We can work with you to ensure that your rights are protected while aggressively fighting your charges.

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