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Medicaid Fraud

Medicaid Provider Fraud

What is Medicaid Provider Fraud?

In South Carolina, Medicaid Provider Fraud is a fraud committed by Medicaid providers against the Medicaid system. Medicaid is administered through the South Carolina Department of Health and Human Services and the United States Department of Health and Human Services. Provider Fraud is fraud committed by those who provide services through the Medicaid program. Doctors, Nurses, Therapists, Counselors, and Home Health Workers can all commit Medicaid Provider Fraud. So can Durable Medical Equipment (DME) Providers.

Medicaid Provider Fraud is what happens when providers try to defraud Medicaid. They do this by submitting false claims for payment. These are Medicaid False Claims. These false claims can be false because fewer services were provided than were actually provided, or because no services were actually provided at all.

Medicaid Fraud is taken very seriously in South Carolina. The Medicaid Fraud Control Unit at the South Carolina Attorney General’s Office is tasked with investigating and prosecuting Medicaid Provider Fraud. The prosecutors there, working in conjunction with auditors and investigators, investigate and prosecute Medicaid Provider Fraud in South Carolina.

If you are charged with Medicaid Provider Fraud, you want an attorney with Experience in dealing with Medicaid Provider Fraud. Judah VanSyckel of Saluda Law, LLC is a former Medicaid Fraud Control Unit prosecutor. He has experience in dealing with Medicaid Fraud cases.

What’s the Applicable Code section?

As of October 8, 2020, one of the applicable statutes in South Carolina is § 43-7-60 of the South Carolina Code of Laws of 1976 as Amended.
Ҥ 43-7-60. False claim, statement, or representation by medical provider prohibited; violation is a misdemeanor; penalties.

  • (A) For purposes of this section:
    • (1) “provider” includes a person who provides goods, services, or assistance and who is entitled or claims to be entitled to receive reimbursement, payment, or benefits under the state’s Medicaid program. “Provider” also includes a person acting as an employee, representative, or agent of the provider.
    • (2) “false claim, statement, or representation” means a claim, statement, or representation made or presented in any form including, but not limited to, a claim, statement, or representation which is computer generated or transmitted or made, produced, or transmitted by an electronic means or device.
  • (B) It is unlawful for a provider of medical assistance, goods, or services to knowingly and wilfully make or cause to be made a false claim, statement, or representation of a material fact:
    • (1) in an application or request, including an electronic or computer generated claim, for a benefit, payment, or reimbursement from a state or federal agency which administers or assists in the administration of the state’s medical assistance or Medicaid program; or
    • (2) on a report, certificate, or similar document, including an electronic or computer generated claim, submitted to a state or federal agency which administers or assists in the administration of the state’s Medicaid program in order for a provider or facility to qualify or remain qualified under the state’s Medicaid program to provide assistance, goods, or services, or receive reimbursement, payment, or benefit for this assistance, goods, or services.
      For purposes of this subsection, each false claim, representation, or statement constitutes a separate offense.
  • (C) It is unlawful for a provider of medical assistance, goods, or services knowingly and wilfully to conceal or fail to disclose any material fact, event, or transaction which affects the:
    • (1) provider’s initial or continued entitlement to payment, reimbursement, or benefits under the state’s Medicaid plan; or
    • (2) amount of payment, reimbursement, or benefit to which the provider may be entitled for services, goods, or assistance rendered.
      For purposes of this subsection, each fact, event, or transaction concealed or not disclosed constitutes a separate offense.
  • (D) A person who violates the provisions of this section is guilty of medical assistance provider fraud, a Class A misdemeanor and, upon conviction, must be imprisoned not more than three years and fined not more than one thousand dollars for each offense.
  • (E) In addition to all other remedies provided by law, the Attorney General may bring an action to recover damages equal to three times the amount of an overstatement or overpayment and the court may impose a civil penalty of two thousand dollars for each false claim, representation, or overstatement made to a state or federal agency which administers funds under the state’s Medicaid program. Upon a finding that the provider has violated a provision of this section, the state agency which administers the Medicaid program may impose other administrative sanctions against the provider authorized by law. A civil or criminal action brought under this section may be filed or brought in either the county where the false claim, statement, or representation originated or in the county in which the false claim, statement, or representation was received by the Health and Human Services Finance Commission or other agency of the State responsible for administering the state’s Medicaid Program.”

What do you need to do if you have been charged with Medicaid Provider Fraud / Submitting False Claims for Payment?

Find a South Carolina lawyer who understands Medicaid Fraud! Judah VanSyckel is a Medicaid Fraud Attorney who previously prosecuted Medicaid Fraud at the South Carolina Attorney General’s Office. Judah VanSyckel of Saluda Law, LLC can help you fight your Medicaid Provider Fraud charges as he is an experienced healthcare fraud attorney. Judah VanSyckel worked with a team of auditors and investigators to prosecute these cases and will use that experience to help you as a Medicaid Fraud defense lawyer. Get help from a Medicaid fraud law firm today.

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