2425 Bristol Court SW -P.O. Box 40114 - Olympia, WA - 98504 - (360) 586-8888
Established in 1978, the Washington State Medicaid Fraud Control Unit is responsible for policing Medicaid providers and Medicaid program expenditures. The WAMFCU is located in the Criminal Justice Division of the Attorney General's Office.
The Unit consists of two sections. The Fraud Section investigates and prosecutes Medicaid provider fraud where the Medicaid program has been falsely billed.
The Resident Abuse Section investigates and prosecutes crimes of abuse and neglect committed against residents in facilities which receive Medicaid funding. They also assist local law enforcement and prosecutors in these cases. Facilities which receive Medicaid funding are nursing homes, adult family homes and boarding homes. It is not necessary that the crime victim be a Medicaid recipient, only that the facility receives Medicaid monies.
What is Medicaid?
Medicaid and Medicare started in 1964. Medicare was designed to provide health insurance to people age 65 and over and those who have permanent kidney failure and certain people with disabilities. Medicaid, on the other hand, is health insurance for qualifying low-income and needy people. Medicaid eligible recipients can include children, the elderly, and persons with a disability.
Each state designs and administers its own Medicaid program. The federal government jointly funds the program as long as the program complies with the requirements mandated by the Center for Medicaid and Medicare services. Medicaid funding and services are administered by the Department of Social and Health Services (DSHS) Medical Assistance Administration, except for the nursing home program, which is administered by the Aging and Adult Services Administration.
Medicaid covered services include hospital care, skilled nursing home care, residential adult family care services, and professional services provided by physicians, and laboratories. Washington Medicaid also includes hospice, mental health, dental services and eyeglasses.
Who Are Providers?
Providers can be any of the following:
- Doctors;
- Nurses;
- Dentists;
- Clinics;
- Ambulance and transportation companies;
- Hospitals;
- Nursing homes;
- Adult family homes;
- Boarding homes;
- Laboratories;
- Pharmacies;
- Home health care providers; and,
- Medical equipment suppliers.
What is Fraud?
Under RCW 74.09.210, FRAUD is an attempt to obtain more benefits or payments than you are entitled to, by means of:
A willful false statement, or
A willful misrepresentation or by concealing material facts, or
By a fraudulent scheme, which may include:
Billing for services, drugs, supplies or equipment that were not furnished or were of lower quality; or substituting or misrepresenting the items billed; or
Repeated billing for purportedly covered items, which were not actually covered.