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NC Department of Health and Human Services
NC Division of
Medical Assistance
 
 

Fraud and Abuse

Medicaid fraud and abuse is when a person knowingly cheats or is dishonest.  The dishonesty results in a benefit such as payment or coverage.

Examples of Medicaid fraud and abuse:

  • An individual does not report all income when applying for Medicaid.
  • An individual does not report other insurance when applying for Medicaid.
  • A non-recipient uses a recipient's card with or without the recipient's knowledge.
  • A provider’s credentials are not accurate.
  • A provider bills for services which were not rendered.
  • A provider performs and bills for services not medically necessary.

Reporting Provider Fraud and Abuse

The N.C. Department of Health and Human Services has created a poster (PDF, 2.0 MB) asking citizens to report Medicaid fraud and abuse.  In a memo (PDF, 75 KB) dated June 4, 2010, DHHS Secretary Lanier Cansler asked all health care agencies and private health care providers to print and prominently display the poster in their offices. 

You are encouraged to report matters involving Medicaid fraud and abuse. If you want to report fraud or abuse, you can remain anonymous; however, sometimes in order to conduct an effective investigation, staff may need to contact you. Your name will not be shared with anyone investigated. (In rare cases involving legal proceedings, we may have to reveal who you are.)

To Report Provider Fraud and Abuse

  • Contact the Division of Medical Assistance by calling the DHHS Customer Service Center at 1-800-662-7030 (English or Spanish) or;
  • Call the Medicaid fraud, waste and program abuse tip-line at 1-877-DMA-TIP1 (1-877-362-8471); or
  • Call the Health Care Financing Administration Office of Inspector General's Fraud Line at 1-800-HHS-TIPS; or
  • Call the State Auditor's Waste Line: 1-800-730-TIPS; or
  • Complete and submit a Medicaid fraud and abuse confidential online complaint form.

To Report Recipient Fraud and Abuse

False Claims Act

Section 6023 of the Deficit Reduction Act (DRA) of 2005 requires providers receiving annual Medicaid payments of $5 million or more to educate employees, contractors, and agents about Federal and State fraud and false claims laws and the whistleblower protections available under those laws. More about False Claims Act

Medicaid Integrity Program Provider Audit

The Deficit Reduction Act of 2005 (DRA) created the Medicaid Integrity Program (MIP) and directed the Centers for Medicare & Medicaid Services (CMS) to enter into contracts to review Medicaid provider actions, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues. More about MIP

PERM

In compliance with the Improper Payments Information Act of 2002, the Centers for Medicare and Medicaid Services (CMS) implemented a Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the State Children’s Health Insurance Program (SCHIP).  Read more about PERM