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Late last month, the U.S. Department of Justice announced a nationwide crackdown on doctors, nurses and other medical professionals it alleged had attempted to defraud government health programs out of $14.6 billion.
Companies sent false billing claims to Medicaid. They took bribes to diagnose and treat conditions that didn’t exist. An addiction treatment provider targeted Native Americans and people who were homeless, billed Medicaid and then never treated them.
This is what Medicaid fraud looks like.
The vast majority of it is committed by providers like hospitals, nursing homes and pharmacies, who receive unearned taxpayer funds through tactics like falsifying records and taking payments for people they never saw, according to public records and former Medicaid officials.
But when explaining their votes for President Donald Trump’s “Big Beautiful” government spending bill, and its massive Medicaid cuts, West Virginia politicians said they were just trying to keep patients from taking advantage of the program.
Republican Sen. Shelley Moore Capito said she didn’t want to cut “anybody’s benefit.”
“But I am interested in making sure that we get rid of the fraud, that we make sure that we have a work requirement, that we make sure we have accountability, and those are money savings in Medicaid,” she said.
Andy Schneider, research professor at the Georgetown University Center for Children and Families and former senior advisor at the Centers for Medicare & Medicaid Services, said that politicians were using terms like “fraud” loosely.
“Regrettably, there is fraud against Medicaid,” Schneider wrote, in a statement Friday. “Most of it is committed by providers, with beneficiaries as the victims.”
Schneider said there are a few provisions of the bill that could address extremely rare cases of beneficiary fraud, including more frequent checks for deceased beneficiaries and address records.
But he noted the four provisions of the bill focused on waste, fraud and abuse save an estimated $25 billion over ten years, only about 2.5% of the nearly $1 trillion the bill cuts from Medicaid during that time.
“If you’re using waste, fraud and abuse in the way those terms are normally used, not political rhetoric, very few of the savings for the federal government in this legislation are coming from waste, fraud and abuse,” he said.
And now, health analysts estimate Medicaid cuts will cost more than 10 million people their health care.
Jeremiah Samples, a former state health official who helped oversee Medicaid in West Virginia, said patient fraud is uncommon.
Examples of patient Medicaid fraud include using someone else’s medical card or reporting inaccurate income.
“It’s like trying to find a needle in a haystack,” he said. “Even if you find the needle, it’s not going to be much money. They focus on what they are able to find and what’s more valuable.”
Sen. Jim Justice, R-W.Va., posted on X that he wanted to eliminate Medicaid fraud.
He acknowledged West Virginia’s reliance on Medicaid in a linked Fox Business interview.
In the older and more low-income state, more than 500,000 West Virginians — nearly one in three people — rely on Medicaid for care like hospital and nursing home stays, heart medications and cancer screenings.
“We don’t have illegals,” the Republican and former governor said. “We don’t have all the abuse and everything, and to absolutely clean it up and make it right for those that are deserving, should we not be doing that?
Under the new law, tens of thousands of his constituents could lose coverage.
Along with Justice and Capito, Rep. Riley Moore and Rep. Carol Miller, also Republicans, voted for the legislation, part of a broader spending bill that also extends tax cuts passed in 2017 and adds $3.4 trillion to the deficit.
Moore said he didn’t want to cut people from the program who needed it but supported provisions to bar states from covering undocumented migrants and eliminate fraud.
In a statement, Miller’s spokesperson said:
“Congresswoman Miller believes this bill is an excellent first step and will continue to monitor if there are even more places to crack down on fraudsters, be that companies, individuals, or governments.”
The offices of Capito, Justice and Moore didn’t respond to questions about why they focused on patients when health care companies are stealing tens of millions.
In its news release about the crackdown last month, the Department of Justice reported it was seizing $245 million in cash, luxury vehicles and cryptocurrency.
Laura Jones, who runs Milan Puskar Health Right, a Morgantown free clinic that also accepts Medicaid, said she doesn’t see any patient fraud.
“If Medicaid is something that an individual uses only if they’re sick, how could you possibly commit fraud?” she said. “If you were making tons of money, you’d have insurance.”
“It isn’t money-making for the patient. They only get what they need.”
Reach reporter Erin Beck at erin@mountainstatespotlight.org
