We’ve seen it before: When great sums of money are in play, an abundance of scammers and fraudsters emerge to capitalize and cheat the system.
It happens in higher ed. In 2019, Duke University paid the US government $112.5 million to settle allegations that it submitted bogus data to win federal research grants.
It happens in the military. In 2018, 3M agreed to pay $9.1 million to resolve accusations that it knowingly sold faulty earplugs to our armed forces, including soldiers stationed in North Carolina.
Medicaid’s recent expansion also creates a fertile opportunity for bad actors to commit fraud in pursuit of a fat check.
The updated North Carolina state budget, which went into place Dec. 1, 2023, qualified an additional 600,000 people for Medicaid coverage. Individuals eligible to receive Medicaid benefits must meet certain income requirements and be between the ages of 19 and 64.
Total enrollment is now around 3 million. About 25% of North Carolinians currently depend on this vast government program for vital healthcare resources.
With so much money and demand pumping through the Medicaid system, it’s no surprise that foul play slips in. Research has estimated that more than one out of five Medicaid dollars will be used for “improper payments” to corporations, pharmacies, hospitals, and others.
Faced with a machine of this daunting scale, does accountability stand a chance? Part of the answer surely involves whistleblowers — people on the inside willing to call out malfeasance.
Enter the False Claims Act, a legal vehicle aimed at ensuring those committing fraud are liable for their actions. Then there’s the Whistleblower Protection Act, which protects and empowers federal employees who speak up about fraudulent actions they’ve witnessed and dishes out punishments for the higher-ups who take action against them for speaking out.
The types of fraud that could potentially be at play are expansive — from bilking seniors by billing for products not provided, to improper upcoding that charges patients more for needed services, to kickbacks for Medicaid patient referrals.
And Medicaid fraud doesn’t just steal from residents and the program itself; every single individual paying taxes is experiencing this theft. When Medicaid money is wrongfully used or stolen, it’s not getting used to support patients that need it.
These jarring truths can be potently seen with a look at the North Carolina Department of Justice’s Medicaid Investigations Division, which has reclaimed $900+ million for the Medicaid program and gathered a staggering 450+ criminal convictions in fraud and abuse cases against healthcare providers. This is even before the expansion of Medicaid, so the universe of potential abuse is now even greater.
This doesn’t just apply to corporate entities either. Any Medicaid provider is liable for fraudulent behavior — from big corporations to small organizations and individuals who are paid by Medicaid for their services. This laundry list includes ambulance businesses, dentists, home health agencies, active adult and nursing homes, pharmaceutical enterprises and doctors, social workers, and other sole healthcare workers, to name a few.
Where big money is found, we may never be free of fraud and foul play. But that shouldn’t discourage vigilance. Whistleblowers play an important role in the ecosystem of accountability. Each successful criminal conviction or civil lawsuit capturing lost funds and redirecting them back to the Medicaid system is a step in the right direction.