Medicaid Fraud Control Unit Frequently Asked Questions
Effective July 1, 2011, the Georgia Medicaid Fraud Unit has been consolidated under the Georgia Department of Law pursuant to an Executive Order by the Governor. Previously, the unit was composed of a three agency task force that included the Georgia Department of Law, the Georgia Bureau of Investigations and the Georgia Department of Audits.
What is the Mission of the Georgia Medicaid Fraud Control Unit?
The mission of the Georgia Medicaid Fraud Control Unit (MFCU) is to serve the public, to uphold and enforce the law, to investigate and prosecute fraud and abuse by providers in the Georgia Medicaid program and to protect vulnerable patients from abuse.
The Unit will strive to accomplish its mission through the determined and energetic pursuit of the following goals:
- To effectively investigate and successfully prosecute health care providers, and others who conspire or act with them, who commit fraudulent or illegal acts in connection with any aspect of the provision of medical assistance or health care services funded through joint federal-state programs.
- To recover, or assist in recovering, federal and state health care funds gained through fraudulent, abusive or illegal acts by healthcare providers, and others who conspire or act with them.
- Through persistent and effective effort in the detection, investigation and prosecution of such fraudulent or illegal acts, to be an effective deterrent to crime, and to help bring about a significant reduction in the level of fraud associated with the providing of health care services funded through joint federal-state programs.
- To collect, initiate civil actions to collect, provide for the collection, or to refer for collection to the Department of Medical Assistance, overpayments that are made under the state plan to health care facilities or other providers of medical assistance, and that are discovered by the Unit in carrying out its activities.
- To establish a program to effectively identify and investigate, or refer for investigation complaints of abuse or neglect of patients in health care facilities receiving payments under the Medicaid program, as well as complaints of the theft, conversion or misappropriation of the private funds of such patients, and to prosecute, refer for prosecution or assist in the prosecution of persons who perpetrate or assist in such unlawful conduct.
- As directed by the Attorney General, to investigate and litigate cases brought under the Georgia False Medicaid Claims Act.
What is the difference between Medicaid and Medicare?
Medicaid is a healthcare program available to those who cannot afford medical care. Those who are eligible for Medicaid include: low-income families, individuals who are disabled, children and the elderly. Medicaid is administered by each individual state, but is jointly funded by state and federal governments. For more information about the Georgia Medicaid Program, visit the following website:
Medicare is a federal program that was created for individuals over the age of 65 and individuals with kidney failure and/or certain disabilities decided upon by Congress. Medicare is managed by the Center for Medicare & Medicaid Services (CMS). CMS is located within the Department of Health and Human Services. For more information on Medicare and Medicare Fraud visit the following websites:
Additionally, the State of Georgia administers a program called "PeachCare for Kids." "PeachCare for Kids" began covering children in 1999, providing comprehensive health care to children through the age of 18 who do not qualify for Medicaid and live in households with incomes at or below 235% of the federal poverty level. Click here for more information about "PeachCare for Kids" and to report PeachCare fraud.
What is Medicaid Fraud?
Medicaid fraud comes in many forms. Some common forms are:
- Billing for services/medication not provided.
- Billing for services/medication not needed.
- Double or over-billing.
- Kickbacks between health care providers and equipment suppliers.
- Criminal abuse and neglect of residents in nursing homes and personal care homes that receive Medicaid funding.
Medicaid fraud also occurs on the receiving side. Medicaid recipient fraud is handled by the Georgia Department of Community Health and prosecuted by your local District Attorney. For more information about recipient fraud and how to find your local District Attorney, follow the links below:
Who works for the Georgia MFCU?
The Georgia MFCU is made up of lawyers, auditors, nurses, investigators and intelligence analysts. These employees work to recover millions of dollars in taxpayer dollars for the state each year.
How much money has The Georgia MFCU recovered?
Since 2011, the Georgia MFCU has recovered over $190 million in taxpayer money, including both state and federal funds. In fiscal year 2013 alone, the office recovered $29.4 million.
How do I report a complaint?
If you suspect that Medicaid fraud may be occurring, report it to the Georgia MFCU.
Where can I find more information about Medicaid Fraud?
For more information on Medicaid Fraud and to learn about other states' MFCUs, visit the National Association of Medicaid Fraud Unit website: http://www.namfcu.net/.