Medicaid Fraud

What is Medicaid Fraud?

Medicaid providers include hospitals, nursing homes, ambulance companies, doctors, dentists, durable medical equipment suppliers, occupational and physical therapists, speech pathologist, orthotic appliance and prosthetic device suppliers, prescription drug dispensers, podiatry service, laboratory services, vision services, rural health clinics, non-emergency transportation broker / companies, HOME HEALTH CARE PROVIDERS, nurses and other suppliers of authorized specialty services.

Some examples of fraud include, but not limited to:

  • Services not rendered / add on services
  • Billing for unnecessary services
  • Substitution of generic drugs
  • Kickbacks
  • Double billing
  • Falsifying documentation
  • Omitting information on nursing notes (i.e. doctor appointments)

It is considered FRAUD to omit or falsify documentation. This includes nursing note, timesheet, and MAR’S.  Timeheets and nursing notes must reflect the actual hours worked.  If you are 10 minutes late your nsg. note and timesheet must reflect the actual hours worked. Please be vigilant and accurate with all documentation!



  1. Always fill out the time sheets with the actual time you worked.
  2. Make sure your nursing notes / time sheet reflect the actual time you cared for your patient.
  3. If scheduling changes need to be made, please contact the office.  Do not just discuss this with the parents; the office needs to be aware of your schedule.
  4. Always write your notes during your shift.  Do not write your notes ahead of time.
  5. Never allow another person to write your nursing notes for you.
  6. Never falsify nursing notes/time sheets or omit information.

Please remember that Medicaid Fraud is a federal offense.  If found guilty of fraud you could serve time in prison, pay restitution, pay a fine of $10,000 and lose your nursing license.


  1. Always check the time sheet to make sure the nurses actually worked those hours.
  2. Do not sign a blank time sheet.
  3. Look at the nursing notes to make sure what is written has actually been done.

Please remember that Medicaid Fraud is a federal offense.  If found guilty, you could serve time in prison, pay restitution, pay a fine of $10,000 and your child could lose their Medicaid eligibility.


White Blood Cells

Leukocytes, white blood cells, are one of the three cellular components of the blood.  The white blood cells can be further broken down into two groups.  One group is the granular leukocytes, are non-granular leukocytes which consist of the monocytes and lymphocytes.

 Neutrophils are present in the bloodstream and act as out primary defense against bacterial infections through a process know as phagocytosis.  In this process, the cells ingest the bacteria and other small unwanted particles.

The eosinophils are involved in our body’s allergic responses and the destruction of certain parasitic worms.  Basophils function as part of the inflammatory response by bringing anticoagulant substances to inflamed tissues during an injury or infection.

Monocytes, one of the non-granular white blood cells, can leave the bloodstream to become part of the injured tissue in order to remove dead or injured cells.  Finally, lymphocytes, which can be found in the lymph system and the bone marrow, participate in cellular immune response and humoral immune response.

The cellular immune response involves specific white blood cells know as T-cells.  These T-cells protect the body from the following:

  1. Chronic bacterial infections (TB, Leprosy)
  2. Many viral infections (measles, chicken pox)
  3. Fungal infections (candidiasis)
  4. Parasitic infections (pneumocytis pneumonia)
  5. Transplanted or transferred cells (tissue transplants)


B-cells are involved with the humorally – medicated immune system.  Through antibodies and immunoglobulin’s, these cells provide major immunity against the following:

  1. Bacteria that produce acute infections (streptococcus)
  2. Bacteria (tetanus, diphtheria)
  3. Viruses that enter the bloodstream (hepatitis)
  4. Organisms that enter the body from mucosal tissue (cold viruses, influenza)

Along with other values, a complete blood county with differentials (CBC with Diff) will give the complete white blood cell count along a with a complete break down of the different types.

Normal WBC count = 5,000 – 10,000 / mm3

Differential count = 100%

Neutrophils                 55 – 70%

Eosinophils                  1 – 4 %

Basophils                     2 – 6 %

Monocytes                  2 – 6 %

Lymphocytes              25 – 40%


What is GERD (acid reflux)?

Gastroesophageal reflex disease commonly referred to as GERD or acid reflux, is a condition in which the liquid content of the stomach regurgitates (back up or refluxes) into the esophagus.  The liquid can inflame and damage the lining (cause esophagitis) of the esophagus although visible signs of inflammation occur in the minority of patients.  The regurgitated liquid usually contains acid and pepsin that are produced by the stomach.  (Pepsin is an enzyme that begins the digestion of proteins in the stomach.  The refluxed liquid also may contain bile that has backed-up into the stomach from the duodenum.  (The duodenum is the first part of the small intestine that attaches to the stomach).  Acid is believed to be the most injurious component of the refluxed liquid.

GERD usually happens because the lower esophageal sphincter (LES) – the muscular valve where the esophagus joins the stomach – opens at the wrong time or does not close properly.  Sometimes reflux causes the burning sensation of heartburn that most of us occasionally feel.

Most reflux occurs during the day when individuals are upright.  In the upright position, the refluxed liquid is more likely to flow back down into the stomach due to the effort of gravity.  In addition, while individuals are awake, they repeatedly swallow, whether or not there is reflux.  Each swallow carries any refluxed liquid back into the stomach.  Finally, the salivary glands in the mouth produce saliva, which contains bicarbonate.  With each swallow, bicarbonate – containing saliva travels down the esophagus.  The bicarbonate neutralizes the small amount of acid that remains in the esophagus after gravity and swallowing have removed most of the liquid.

Gravity, swallowing and saliva are important protective mechanisms for the esophagus, but they are effective only when individuals are in the upright position.  At night during sleep, gravity is not in effect, swallowing stops, and the secretion of saliva is reduced.  Therefore, reflux that occurs at night is more likely to result in acid remaining in the esophagus longer and causing greater damage to the esophagus.


What Causes GERD?

No one knows for sure why people get GERD.  Although lots of different things may contribute to the condition, doctors believe that the way the LES works is the main reason why people have gastroesophageal reflux.

The LES is a muscular ring at the bottom of the esophagus where it joins the stomach.  As a person swallows, muscles in the esophagus move the food down in to the stomach.  The LES relaxes just enough to allow food and liquids into the stomach, but then the powerful muscles in the LES contract (tighten) to stop food and liquids from moving back up the esophagus.  In other words, the job of the LES is to prevent reflux.

Sometimes, though, the LES might not be able to do its job for various reasons. In some peoples, the LES doesn’t tighten properly.  In other cases, the LES doesn’t close quickly enough or at the right time, allowing stomach contents to wash back up.

If a person has eaten way too much, the stomach may be so stretched full that LES can’t do its job properly.


Signs and Symptoms of GERD

The possible manifestations of GERD are many and varied.

  • A sore, raw throat or hoarse voice
  • A frequent sour taste of acid, especially when lying down
  • A feeling of burping acid into the mouth
  • Trouble swallowing
  • A feeling that food is stuck in the throat
  • A feeling of choking that may wake someone up
  • A dry cough
  • Bad breath
  • Irritability or pain
  • Swallowing increased
  • Grimacing
  • Vomiting
  • FTT
  • Regurgitation


Predisposing Factors

  • Non-ambulatory
  • Scoliosis
  • Cerebral palsy
  • Use of anticonvulsive therapy
  • Severity of mental retardation


Other Factors

Gastrostomy feeding.  Two studies compared the presence of gastrostomy feeding in people with and without GERD. In one study GERD patients more frequently had gastrostomy feeding.  In the other study no differences were found.  Three studies were included that evaluated the presences of GERD after placement of a gastrostomy tube.  In these studies the subjects were not diagnosed as GERD patients before placement.  No further anti-reflux surgery was done (e.g. Nissen fundoplication).  The percentage of subjects who developed GERD afterwards was 60%, 27% and 6% respectively.  It can be concluded that gastrostomy feeding may trigger GERD, but the evidence is not firm


Treatment for GERD

  • Recognize symptoms, vent GT during periods of reflux to prevent aspiration.
  • Allow vomiting via GT to avoid risk of aspiration.
  • Medications prescribed by doctor.  Antacids (Maalox), acid blockers (Zantac, Pepcid).
  • Remain upright after GT feeding and meals to enhance gravity and prevent aspiration / pneumonia.
  • Monitor volume of food – if volume is increased then reflux will increase.
  • Surgery – Nissen which will tighten the LES sphincter, back-up the stomach and esophagus.