Reporting Medicaid Fraud and Abuse

Medicaid fraud and abuse cost states billions of dollars every year, diverting funds that could otherwise be used for legitimate health care services.

Not only do fraud and abuse increase the cost of Medicaid without adding value, they increase risk and potential harm to people who are exposed to unnecessary services or procedures.

Medicaid fraud occurs when a member or provider knowingly cheats or is dishonest, resulting in a benefit such as payment or coverage that would not have been provided.

Examples of Medicaid fraud:

• Knowingly billing for services or supplies not provided.
• Knowingly billing for more services than were actually provided.
• Paying for referrals and/or accepting payment for referrals.
• Using someone else’s Medicaid ID to receive services.
• Not reporting all income when applying for Medicaid.

Medicaid abuse occurs when a member or provider engages in activity that results in unnecessary cost, including services that are not necessary or services that do not meet the standards of care.

Examples of Medicaid abuse:

• Billing for services that are not necessary.
• Billing for services individually that were provided to a group, referred to as unbundling.
• Assigning inaccurate codes when billing to increase payment, referred to as upcoding.

Alliance is working closely with local, State, and Federal agencies to make behavioral health services more accessible [toc]during this public health crisis. Unfortunately, times of crisis are often exploited by fraudsters and the U.S. Department of Health and Human Services Office of the Inspector General has alerted the public about fraud schemes related to COVID-19 – click here for more information. Alliance wants you to know that we are putting measures in place to balance access to services with detection of fraud and abuse. Our team of investigators and auditors continuously review claims for services to identify possible fraud and will continue to do so throughout this crisis. Please see below for fraud prevention and how to report Medicaid fraud.

These examples of Medicaid fraud and abuse sound similar. Figuring out the difference between Medicaid fraud and abuse requires investigation. If you know or believe that Medicaid fraud or abuse is happening, please report it so it can be properly investigated. If you want to make a report, you can remain anonymous, but sometimes we may need to contact you in order to conduct an effective investigation. Your name will not be shared with anyone who is being investigated, but in rare cases involving legal proceedings we may have to reveal who you are.

Helpful information to include in a report:

• The name or names of the members.
• The name or names of the providers.
• The date or dates of the services.
• A description of the acts that you suspect involve Medicaid fraud or abuse.

How to report Medicaid fraud and abuse:

• Call the Alliance confidential Fraud and Abuse Line at (855) 727-6721.
• Contact the Division of Medical Assistance by calling the DHHS Customer Service Center at (800) 662-7030.
• Call the Medicaid Fraud, Waste and Program Abuse Tip Line at (877) DMA‐TIP1 or (877) 362-8471.
• Call the Health Care Financing Administration Office of Inspector General’s Fraud Line at (800) 447-8477.
• Call the State Auditor’s Waste Line at (800) 730-TIPS or (800) 730-8477.
• Complete and submit a Medicaid fraud and abuse confidential online complaint form by going to the DHHS Customer Service website.

• Your Medicaid card and number are yours. Do not let anyone else use them.
• Do not give your Medicaid number to a stranger or in exchange for a special offer.
• Remember that Medicaid does not pay for mentoring, after-school programs, summer camps, or tutoring.
• Ask for a written description of the services offered to you.
• Do not agree to services that you do not think you or your child need.
• Do not sign a blank form.
• Write down the names of the people that provide your services, the agencies they work for, and the dates the services are provided.

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