The State of
Delaware and the Federal Government have designated the
Medicaid Fraud Control Unit (MFCU) to investigate and
prosecute illegal acts relating to Medicaid funds. Created in
1980, the MFCU, which is housed within the Delaware Department
of Justice, is designed to protect the Delaware residents who
receive Medicaid and the taxpayers who support the program.
The MFCU has a professional staff of prosecutors,
investigators and auditors who review allegations involving:
Medicaid Fraud: civil or criminal fraud
against the state by healthcare providers who treat Medicaid
Patient Abuse, Neglect or Mistreatment:
criminal abuse, neglect or mistreatment of patients in
health-care facilities, including nursing homes and mental
health residential facilities.
Financial Exploitation: theft or misuse of
funds belonging to residents of
Delaware Health care facilities.
WHAT IS MEDICAID?
Medicaid is a federal/state cost-sharing program that provides
healthcare to people who are unable to pay for such care. The
Delaware Medicaid program is administered by the Delaware
Department of Health and Social Services.
The MFCU does not investigate fraud committed by Medicaid
recipients; such cases should be referred to the Welfare
Fraud Unit (Audit recovery management systems) within the
Department of Justice.
WHAT IS MEDICAID PROVIDER FRAUD?
Medicaid providers include doctors, dentists, hospitals,
nursing homes, clinics, pharmacies, ambulance companies and
anyone else who is paid by Medicaid for a healthcare service.
Fraud by a Medicaid provider is usually evidenced by one or
more of the following:
UPCODING - when healthcare providers bill
Medicaid for a more expensive treatment or service than the
one they actually provided to the patient; or by filling a
prescription with a generic drug, while billing for the more
expensive name brand version of the medication;
PHANTOM BILLING - billing for goods or services
not provided, such as
billing for patient visits that never took place or for blood
tests when no
samples were taken;
UNNECESSARY SERVICES - billing for unnecessary
include billing for items that patients do not need at all,
such as oxygen
concentrators, hospital beds or wheelchairs;
DOUBLE BILLING - billing Medicaid twice for the
sometimes by submitting a bill at the beginning of the month
second bill at the end for the same service;
UNBUNDLING - submitting bills for individual
procedures as if the service
were performed on different days for procedures that the
performed during one day as part of one operation;
KICKBACKS - when medical suppliers, home health
agencies, etc., give
things of value to other health care providers in exchange for
Acts like those described above may violate state and federal
laws and subject
the guilty provider to imprisonment, significant fines and
exclusion from the Medicaid
HOW DOES MEDICAID FRAUD AFFECT ME?
Medicaid fraud affects everyone. When providers steal from
decrease the resources available to the program. Residents
living near the poverty
level, who would have been qualified for the program, might be
excluded because of a lack of resources. Medicaid fraud also
reduces the quality of treatment as dishonest providers try to
reduce costs and increase personal profit. To compensate for
the fraud, the state must either decrease services in other
areas or raise taxes.
HOW CAN I SPOT MEDICAID FRAUD?
Many of the cases prosecuted by the MFCU start with
information from the public.
Here are several hints to help detect possible fraud:
if a provider suggests treatment or services that you do
not realistically believe are necessary, be cautious of the
if you receive Medicaid and are in a healthcare
facility, check your personal funds account regularly;
if you are visiting in a healthcare facility, pay
attention to the patient's appearance and the appearance of
the room and the facility or any other indication of neglect.
HOW CAN I REPORT MEDICAID FRAUD?
You can anonymously report Medicaid Fraud by calling the
Department of Justice Healthcare Provider Fraud Hotline at