Reporting Fraud, Waste and Abuse (FWA)

Improper payments, including payments due to fraud, waste and abuse, cost the US billions of dollars every year. The information on this page describes fraud, waste and abuse, provides examples, and explains how you can report it.

Fraud happens when people or providers knowingly cheat or are dishonest in order to get benefits.

Waste is the overuse of services or other practices that result in costs that are not needed and do not help improve health outcomes.

Abuse is when people or providers take part in an activity that results in extra cost, such as services that are not needed or services that do not meet the standards of care.

Examples of FWA:

• Providers bill for services or supplies that were never given
• A provider bills members for more expensive services than given
• A provider offers money or gifts for member referrals or services
• Giving false information to be eligible for Medicaid or State-funded benefits
• A provider orders lab tests or procedures that are not needed to increase billing
• A pharmacy bills Medicaid for a brand name drug but gives the member the generic form
• Unqualified staff providing services

• Review your Explanation of Benefits (EOB)
• Write down and keep records of your appointments and treatments
• Remember to guard your information – do not share your Medicaid ID or personal information
• Report suspicious activity- if it does not feel right, report it

If you suspect fraud, waste or abuse you can:

• Call Alliance Health Compliance Line at 1-855-727-6721
• Call the Medicaid Fraud, Waste and Program Abuse Tip Line at 1-877-362-8471
• Call the State Auditor’s Waste Line at 1-800-730-TIPS (1-800-730-8477)
• Call the U.S. Office of Inspector General’s Fraud Line at 1-800-HHS-TIPS (1-800-447-8477)
• Submit a Medicaid fraud and abuse confidential (private) online complaint form by going to the DHHS Customer Service website

Filing a complaint: 

Include as much information as possible such as:

• Your contact information (email, telephone number)
• Member’s name, date of birth and address
• Description of the allegation (suspected FWA)
• Evidence to support the allegation (photographs, text, emails)
• Provider’s name, location (address) and contact information
• Service provided/billed for
• Staff involved
• Names and phone numbers for anyone that can attest to the allegation
• Timeline of allegation
• If reported to the provider, information about that report (who, when, results)

Call Alliance Health Member and Recipient Services at 800-510-9132 if:

• You have a change in Medicaid eligibility
• There is a change in household family members
• There is a change in Medicaid coverage for you or your children

Four Rs for Fighting Health Care Fraud
U.S. Department of Health and Human Services “Compliance 101”
CMS Medicaid Fraud Prevention Toolkit
NC False Claims Act 
Anti-Kickback Statute
Commonly Referenced Laws in Healthcare Fraud