Washington State Medicaid Fraud Control Unit

Established in 1978, the Washington State Medicaid Fraud Control Unit investigates and prosecutes  fraud by health care providers. The unit also monitors complaints of  resident abuse or neglect in Medicaid funded nursing homes, adult family homes and boarding homes providing valuable assistance to the local law enforcement  in investigating and prosecuting crimes committed against vulnerable adults.  The WAMFCU is part of  the Corrections Division of the Attorney General's Office.

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.

The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the U.S. Department of Health and Human. You can learn more about the programs online at http://www.cms.hhs.gov/.

Who Are Providers?

Providers can be any of the following:

• Doctors
• Nurses
• Clinics
• Hospitals
• Nursing homes
• Adult family homes
• Boarding homes
• Laboratories
• Pharmacies
• Ambulance and transportation companies
• Home health care providers
• Medical equipment suppliers

What is Fraud?

Medicaid Fraud is generally defined as the billing of the Medicaid  program for services, drugs, or supplies that are:

• Unnecessary
• Not performed or are of a lower quality
• More costly than those actually performed
• Purportedly covered items, which were not actually covered