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What is Medicaid?

Joint Federal and State program for free or low cost health care for low income people, families, children, pregnant women, the elderly and people with disabilities

What is Medicaid Fraud Control Unit?

The Medicaid Fraud Control Division is a criminal law enforcement unit of the Office of the Attorney General that enforces the Medicaid Fraud Act and the Resident Abuse and Neglect Act. The Division investigates and prosecutes Medicaid providers who commit fraud and resident abuse, neglect, and exploitation in long-term care facilities. The unit also pursues civil monetary repayment of Medicaid program funds when a Medicaid provider does not provide adequate services to recipients. The Division participates in multi-state cases to recover Medicaid funds that are inappropriately utilized by nationwide Medicaid providers. The Division staff is comprised of attorneys, investigators, auditors, and administrative staff. The Division receives 75% of its funding from a federal grant and 25% from the New Mexico Legislature.

What We Do

Investigate and prosecute fraud committed by Medicaid providers, including hospitals, nursing homes, laboratories, doctors, dentists, nurses, caretakers, therapists, facilities, etc.
Investigate and prosecute abuse, neglect, and exploitation against residents in facilities, including assisted living facilities and nursing homes.

Who are “Providers”?

Any provider of medical services. Dentists, Counselors, Psychiatrist, Psychologists, Nurses, Optometrists, Opticians, Radiologists, Technicians, Ambulance Technicians, Physicians, Nursing Homes, Residential Facilities, Hospitals, Home Care Agencies, Substance Abuse Treatment Centers, Laboratories, Personal Home Healthcare Providers, Pharmacies, Pharmacists, Medical Equipment Providers, Radiologists, Pharmaceutical Companies.

Statutory Authority

New Mexico Statutes

  • 30-44-1 Medicaid Fraud Act
  • 30-47-1 Resident Abuse & Neglect Act
  • 44-9-1 Fraud Against Taxpayers Act

New Mexico Administrative Codes (NMAC’s)

Types of Investigations

  • Billing for services not provided
  • Caretaker timesheet investigations
  • Billing  for services by or for deceased, incarcerated, or nonexistent individuals
  • Nursing Home, Assisted Living, and Facility Abuse/Neglect Allegations
  • Double billing for services
  • Upcoding- billing for a higher level of service than what was provided
  • Falsification or failure to retain documentation
  • Services that are essentially worthless or substantially inadequate care
  • Bribes in connection with the furnishing of treatment, services or goods for which payment was made
  • Kickback schemes involving Medicaid money
  • Whistleblower actions brought by an individual on behalf of the government

Who We Work With

  • Adult Protective Services
  • Local Law Enforcement
  • District Attorney
  • United States Attorney
  • Department of Health
  • Human Services Division
  • Regulation & Licensing
  • US Dept. of Health & Human Services
  • FBI
  • Homeland Security Investigations
  • Other Medicaid Fraud Control Units