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Regulators Need All the Help They Can Get Fighting Medicaid Fraud

Medicaid fraud costs taxpayers hundreds of millions of dollars. In 2012 and in 2013, the Texas Office of Inspector General indicated that $1.1 billion in Medicaid provider overpayments had been identified. The Office of Inspector General is vested with the responsibility of identifying and fighting fraud in order to try to recover funds. Yet, according to Insurance News, only $5.5 million in provider overpayments were collected from 2012 to 2013. money

Insurance News reported a recent assessment from the Sunset Advisory Commission, which is responsible for reviewing state agencies to determine how the agencies perform. The Commission found the Texas agency responsible for fighting Medicaid fraud is "poorly managed, occasionally unfair to those it investigates and has failed to do an effective job identifying and recovering money." When the state agency fails at its efforts, the public suffers, as do those who need assistance from Medicaid. Whistleblowers are even more invaluable at fighting fraud when government regulators are not able to do so on their own, so a Medicaid fraud attorney in Texas should be consulted if you believe you may know of fraud occurring.

State Regulators Failing at Fighting Medicaid Fraud

The Health and Human Service Commission's Office of Inspector General takes many years to close investigations into medical care providers who take Medicaid payments. The Office also fails to distinguish effectively between minor mistakes and serious transgressions, and it misuses the authority that it has to unfairly withhold government Medicaid payments from providers in order to compel financial settlements.

Medicaid fraud has become a major issue as providers bill procedures they don't perform, or as providers do work that should not be covered because it is not medicinally necessary. Dentists, especially, may be engaging in high levels of Medicaid fraud after a class action lawsuit settlement established a mandate that the state of Texas spend more money on dental care for poor children. Spending on dental care soared after this 2007 settlement. Spending on orthodontic care also went up significantly over that same period of time.

State agencies have tried to stop abuses and to go after dentists and orthodontists to recover improper payments. In some cases, this has ended up forcing dentists out of business when funds are withheld. Unfortunately, while stopping actual Medicaid fraud is a good thing, providers have fought back in many cases and argued that the contested procedures had been approved by the Texas Medicaid and Health Partnership. This is a private contractor that the state hired to assess whether a procedure should be covered by Medicaid or not.

The regulators have not been effective at recovering money, even with their aggressive and sometimes unfair approach. One company that owed more than $16 million, for example, ended up paying back just $39,000 in a negotiated settlement. The state Office of Inspector General's investigations have only led to a total of $14 million in legal settlements from just a dozen providers.

If regulators are not able to stop fraud on their own, it is essential for whistleblowers to come forward, take action and fight to protect taxpayer dollars.

Contact a Houston, TX Medicaid fraud attorney if you believe you have evidence of fraud. Call Brewer & Prichard P.C. today at 800-445-8710  or visit to schedule a consultation.