Medicaid fraud in South Carolina largely tied to health care providers | Your Health

When the Justice Department announced in July that the federal government would press charges against more than 400 health care providers, including 115 doctors, in the largest health care fraud bust in history, U.S. Attorney General Jeff Sessions called it “a historic day.”

“Too many trusted medical professionals like doctors, nurses, and pharmacists have chosen to violate their oaths and put greed ahead of their patients,” Sessions said in the announcement. “Amazingly, some have made their practices into multimillion dollar criminal enterprises.”

No one from South Carolina was named in the takedown, which alleged that these providers submitted $1.3 billion in false claims to the federal Medicare, Medicaid and Tricare programs, but that doesn’t mean health care fraud doesn’t exist here. New numbers provided by the S.C. Attorney General’s Office show state investigators have identified millions in Medicaid fraud in the Palmetto State in recent years. And overwhelmingly, health care providers are the ones at fault.

Between 2012 and 2016 in South Carolina, Attorney General Alan Wilson’s office recovered more than $90 million in fraud tied to providers and, during the same five years, recovered about $2.8 million in fraud tied to Medicaid recipients. 

One reason the recovery amounts between provider and recipient fraud are vastly different is because it’s more difficult for Medicaid patients to defraud the system. Patients may lie about their income on their application and the state Medicaid agency may not catch the false information during the income verification process, but those cases are relatively rare and the fraud is typically detected within a relatively short time frame. 

On the other hand, one provider who defrauds the system may treat hundreds of patients over several years, said Nancy Cote, who heads the Medicaid Provider Fraud section in the S.C. Attorney General’s Office.

“Provider fraud cases cut across a wide range of behavior over a longer period of time, which explains why the amount of money involved is greater,” she said. 

In one recent case, Cote said, South Carolina recovered $5 million from the pharmaceutical company Wyeth. Investigators alleged the company knowingly “concealed, avoided or decreased an obligation” to pay drug rebates for certain medications to the state Medicaid program. That case involved other states and many patients. 

If you suspect a health care provider is committing Medicaid fraud, you can place an anonymous tip to the Attorney General Alan Wilson’s office by calling 1-888-NO-CHEAT. If you suspect a Medicaid beneficiary is defrauding the system, call the S.C. Department of Health and Human Services at 1-888-364-3224.

Reach Lauren Sausser at 843-937-5598. 

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