The Colorado Medicaid Fraud Control Unit’s (MFCU) mission is to protect state and federal funds from fraud against Medicaid by individuals or companies who provide services; and to protect residents of long-term care facilities from physical or threatened abuse, mental or emotional abuse, sexual abuse, criminal neglect, and financial abuse.
The MFCU employs a professional staff of criminal investigators, an auditor, a nurse investigator, and prosecutors experienced in criminal and financial investigations.
The MFCU’s abuse jurisdiction extends to all personal care boarding homes, adult day care facilities, hospitals, skilled nursing centers, rehabilitation centers, long-term facilities, and some assisted living centers – regardless of whether the patient is a Medicaid recipient or not; the Unit does not investigate abuse in the home or in non-Medicaid facilities. Our fraud jurisdiction covers all Medicaid providers.
The MFCU has authority to hold individuals or entities accountable through criminal prosecution and/or civil litigation. The Unit also makes recommendations to the U.S. Department of Health and Human Services, Office of the Inspector General to exclude individuals or entities from participating in Federally-funded programs.
If you are a victim of fraud, abuse, or neglect by a Medicaid provider, or if you know of or suspect an at-risk adult or juvenile, or a person with a developmental or physical disability is a victim of these crimes, you should contact your local law enforcement agency or the Medicaid Fraud Control Unit.
Fraud against Medicaid by recipients is investigated by each county through the local office of the Colorado Department of Human Services.
Receiving Medicaid services is critical for many Coloradans, and our goal is to effectively investigate, prosecute, and recover overpayments for the State Medicaid Program; and to ensure the safety of long-term care patients in Medicaid funded facilities.
The MFCU is a member of:
- National Association of Medicaid Fraud Control Units
- Joint Health Care Fraud Task Force
- Special Investigations Unit Working Group
Fraud by Individuals Who Receive Services
The MFCU does not investigate individuals who receive services as part of the Medicaid Program.
The county office of the Colorado Department of Human Services investigates recipient fraud, and the local District Attorney’s Office prosecutes those individuals who practice fraudulent schemes. Recipient fraud can be:
- Falsifying information on applications in order to receive benefits;
- Loaning your Medicaid ID card to others;
- Changing or faking an order or prescription;
- Using more than one Medicaid ID number;
- Deliberately getting duplicate or excessive services and/or supplies; or,
- Selling supplies given by Medicaid to others.
Of course there are other forms of fraud as well. If you know of, or suspect recipient fraud is being committed, please contact the local Colorado Department of Human Services office in the county where the recipient is receiving services.
Employers and Excluded Individuals
Employers who participate in the Medicaid program are required to ensure that employees, subcontractors, and vendors are not excluded or disqualified from the Medicaid program.
When excluded, no program payment will be made for anything an excluded person or entity provides. This applies to the excluded person, anyone who employs or contracts with the excluded person and any facility where the excluded person provides services, regardless of who submits the claims.
Employers and contractors should check the U.S. Department of Health and Human Services, Office of the Inspector General Exclusion Database for a national list of excluded individuals, and the U.S. Excluded Parties List System for a national and international list of excluded individuals periodically to make sure they are not billing Medicaid for services associated with an excluded individual or entity. Failure to do so may result in a civil penalty for each claim.
- What’s the difference between Medicaid and Medicare?
- Who are providers?
- What is Medicaid fraud?
- How can I spot Medicaid fraud?
- What if I suspect a provider is committing or has committed fraud?
- What are some examples of abuse?
- What can I do if I suspect someone is being or has been abused?
- What is neglect?
- What can I do if I suspect someone is being or has been neglected?
- What is medical identity theft?
- Can I file a whistleblower lawsuit alleging fraud by a provider?
Although their names are similar, Medicaid and Medicare are very different programs and are both administered through the Centers for Medicare and Medicaid Services.
Medicaid is health insurance for qualifying low income, disabled individuals, and children and families. Medicaid covered services include hospital care, skilled nursing home care, residential adult family care services, hospice, mental health, dental and eyeglass services, and professional services provided by physicians and laboratories. Medicaid is managed by the states.
Medicare is designed to provide health insurance to people age 65 and over, people of all ages who have permanent kidney failure, and people of all ages with certain disabilities. The Medicare Program provides a Medicare Part A which covers hospital bills, Medicare Part B which covers medical insurance coverage, and Medicare Part D which covers prescription drugs. Medicare fraud is investigated by U.S. Department of Health and Human Services, Office of the Inspector General. The Centers for Medicare and Medicaid Services is the organization that manages Medicare.
Providers are any company, organization, or individual, or an employee or agent of a company, organization, or individual that provides goods or services to Medicaid recipients for which payment is claimed under Medicaid 42 C.F.R. § 1000.30. This includes:
- Counselors, Psychiatrists or Psychologists;
- Nurses, CNAs, PAs or NPs;
- Optometrists or Opticians;
- Radiologists or Technicians;
- Ambulances and Transportation companies;
- Hospitals or Clinics;
- Nursing homes and other long-term care facilities;
- Home care agencies;
- Substance abuse treatment centers;
- Adult family homes;
- Personal care boarding homes and group homes;
- Pharmacies or Pharmacists;
- Pharmaceutical manufacturers;
- Home health care providers;
- Businesses that provide medical equipment or supplies; or
- Any other service if it is paid for by Medicaid.
Medicaid Fraud is an attempt to obtain more benefits or payments than you are entitled to, by means of:
A willful false statement, a willful misrepresentation or by concealing material facts, or by a fraudulent scheme such as:
- Billing for services, drugs, supplies or equipment that were not furnished, or were of lower quality;
- Substituting or misrepresenting the items billed;
- Repeated billing for purportedly covered items, which were not actually covered;
- Ordering unnecessary services;
- Incorrect coding, i.e., supplying a regular office visit but billing for something more;
- Calling for the Medicaid recipient to come back to the provider's office, even when it's obvious additional appointments are not necessary;
- Using unauthorized suppliers for the services that only authorized professionals should give, and then billing them as if the authorized supplier gave the services;
- Providing a set amount of services based on time and then billing for more time than was really provided;
- Billing for office visits that didn't actually occur;
- Payment of kickbacks for the referral of a recipient to a provider; or,
- Medical identity theft.
This is a small sampling of the types of fraudulent schemes providers have attempted.
If you receive an Explanation of Benefits (EOB) from Medicaid, read it carefully. If the information is not correct or is different than the services you received, contact the Medicaid office shown on the bill.
If a provider suggests treatments or services that you do not believe are necessary, it’s okay to be cautious of the recommendation and to ask for a second opinion.
If you suspect a provider is committing or has committed fraud, report it immediately. Call the Colorado Attorney General's Medicaid Fraud Control Unit at 720-508-6696, or file a complaint online.
Abuse can be physical, mental, emotional, or sexual. Drug theft is also a form of abuse, as well as financial exploitation such as theft of a patient needs funds or of a patient’s identity.
Because at-risk adults, at-risk juveniles, and persons with developmental or physical disabilities are often completely dependent upon the care provided by caregivers and/or facilities, they are particularly vulnerable to abuse and neglect.
It's not necessary that the abused patient receives Medicaid, only that the facility where the patient is located receives Medicaid money, no matter how small the amount.
Physical abuse involves, but is not limited to:
- Excessive force in the course of a prescribed treatment or therapy;
- Unnecessary physical contact when providing care;
- Slapping, punching, or kicking;
- Shoving or shaking; or,
- Physical restraints.
Some signs of physical abuse include:
- Welts, bruising, or other wounds;
- Redness and/or swelling;
- Frequent unexplained injuries;
- Untreated injuries in different healing stages;
- Complaints of pain without obvious injury;
- Unexplained signs of injury such as bruises, welts, or scars, especially if they appear symmetrically on two sides of the body;
- Lack of reaction to pain; or,
- Fear of being alone with caregivers.
Less obvious signs of physical abuse include broken eyeglasses, sudden changes in behavior, or the caregiver’s refusal to let visitors be alone with the victim.
Sexual abuse is any form of nonconsensual sexual contact. Identifying and treating elder sexual abuse is difficult because elders are less likely to report it, and the symptoms could be the same as other conditions the elderly may be experiencing. Cognitive impairments may make it difficult for the older victim to explain or remember the abuse. It is important that those who are involved with elders are able to recognize signs of sexual abuse to aid in detection and treatment of victims.
Physical Signs of Sexual Abuse include:
- Injury to the genital area;
- Sexually transmitted diseases;
- Difficulty walking or standing;
- Pain and/or itching in the genital area; or,
- Exacerbation of existing illness.
Emotional signs include:
- Scared or timid behavior;
- Depressed withdrawn behavior;
- Sudden changes in personality;
- Odd or misplaced comments about sex or sexual behavior; or,
- Fear of certain people or of physical characteristics.
Financial exploitation is the exploitation of a resident by a facility in which they reside or exploitation by an employee of that facility.
If you suspect that an at-risk adult or juvenile, or a person with developmental or physical disability has been abused, or a resident’s patient needs funds are being used improperly, call the police, and then call the Colorado Attorney General's Medicaid Fraud Control Unit at 720-508-6696, or file a complaint online.
Neglect is a pattern of conduct, without the person’s informed consent, resulting in deprivation of food, water, medication, medical services, shelter, heating or cooling, or other services necessary to maintain minimum physical or mental health.
Neglect can also involve excessive delays in response to patient needs, and it can take place with physical, mental, and emotional abuse.
If you suspect that an at-risk adult or juvenile, or a person with a developmental or physical disability is being or has been neglected, report it immediately, call the police and then call the Colorado Attorney General's Medicaid Fraud Control Unit at 720-508-6696 or file a complaint online.
It is a crime for anyone to unlawfully use your personal medical information. This would include an individual using your insurance information to obtain medical services or a medical provider using your insurance information to bill for services you did not receive.
Persons who have specific personal knowledge of fraud being perpetrated against the Medicaid system may file a “whistleblower” (qui tam) lawsuit against the provider under Colorado’s Medicaid False Claims Act, C.R.S. 25.5-4-304 to 310. Suits are filed in the name of the State and are “under seal,” which means they are filed in secret and are not initially served or provided to the defendant. A prevailing plaintiff can be awarded a percentage of the recovery gained by the State if certain conditions are met.
The state will investigate the allegations in the whistleblower suit before it is served on the provider, and decide whether or not to intervene in the case. If it does, attorneys for the State will handle the case while the whistleblower participates and assists. If the State does not intervene, the whistleblower is left to press the case on his or her own. Until the case is “unsealed” by court order, the whistleblower must not reveal its existence nor discuss the case publicly.
The False Claims Act also provides a remedy for whistleblowers who are still employed by the defendant/provider, if they believe they have been retaliated against by their employer.
For more information about filing a whistleblower lawsuit contact an attorney with knowledge in this area, and see Colorado Revised Statutes 25.5-4-304 to 310.
Additional Resources and Information
- I have questions about my eligibility or benefits.
- I think I know a recipient who committed fraud, what do I do?
- Where can I find a list of excluded individuals and entities?
I have questions about my eligibility or benefits
If you have questions about enrolling in Medicaid, your eligibility, benefits, and services, contact the Colorado Department of Human Services, or the Colorado Department of Health Care Policy & Financing. They can answer your questions and help to make sure you get the services you need.
I think I know a recipient who committed fraud, what do I do?
To report Medicaid recipient fraud, contact the Colorado Department of Human Services and file a report in the county where the recipient is receiving services.
Where can I find a list of excluded individuals and entities?
The U.S. Department of Health and Human Services, Office of the Inspector General maintains a current list of excluded individuals and entities, or you can visit the U.S. Excluded Parties List System, which is another resource that helps you quickly locate information on parties that are excluded from receiving Federal contracts, certain subcontracts, and certain Federal financial and nonfinancial assistance and benefits.
The National Center on Elder Abuse (NCEA) is dedicated to ensuring that older Americans live with dignity, integrity, independence, and without abuse, neglect, and exploitation.
A program with the Colorado Attorney General and the AARP Foundation that fights the exploitation of older Coloradans
Helpguide provides information that empowers people with knowledge and hope to resolve life’s challenges.
Provides information and training tools to help prevent elder/adult abuse, and promotes the rights of elders.
CMS administers both the Medicare and Medicaid programs on the federal level.
The Department administers the state Medicaid and Child Health Plan Plus programs as well as a variety of other programs for low-income families, the elderly and persons with disabilities.
CDHS is a state-supervised, county-administered system for social services, including programs such as public assistance and child welfare services.
The District Attorney’s Office advises and consults in the deterrence and prevention of crime and is a primary point of contact for local communities.
The National Association of Medicaid Fraud Control Units promotes communication and interstate cooperation between the 50 federally certified MFCUs.
HHS OIG protects the integrity of Department of Health and Human Services (HHS) programs, as well as the health and welfare of the beneficiaries of those programs.
The EPLS provides information on parties that are excluded from receiving Federal contracts, certain subcontracts, and certain Federal financial and nonfinancial assistance and benefits.
File a complaint online with the Medicaid Fraud Control Unit.
Colorado Department of Law
Medicaid Fraud Control Unit
Ralph L. Carr Colorado Judicial Center
1300 Broadway, 9th Floor
Denver, CO 80203
Confidential fax 866-858-7486
Report Fraud in Another State
If you have information about fraud or abuse in another state please contact the National Association of Medicaid Fraud Control Units.