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North Carolina Department of Justice
North Carolina Department of Justice
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Stop Health Fraud

The Attorney General's Medicaid Investigations Division investigates and prosecutes health care fraud committed by Medicaid providers and the physical abuse of patients and embezzlement of patient funds in Medicaid funded facilities.
 
Our Medicaid Investigations Division (MID) is staffed by Department of Justice attorneys, SBI agents, investigators and auditors who are trained in the complexities of health care fraud litigation.

Over the past decade, the NC MID has recovered more than $400 million and helped win more than 450 criminal convictions in health care fraud and abuse cases.
 
The MID handles the following types of cases:
  • Fraud committed by Medicaid health care providers;
  • Physical abuse of patients in Medicaid funded facilities;
  • Embezzlement, theft, and improper commingling of patients' funds in Medicaid funded facilities.
 
We work closely with United States Attorneys, District Attorneys, Federal and State law enforcement agencies, and private insurance company fraud units.
 
Our joint investigations of Medicaid fraud, Medicare fraud, Tricare (a military health insurance program), and private insurance fraud can result in criminal charges against health care providers who break the law as well as civil actions to recover overpayments and penalties.
 
Physical Abuse of a Patient
 
When any provider or employee of a Medicaid funded facility, such as nursing home, rest home or state hospital, physically assaults any resident the MID can investigate. We can investigate abuse whether or not it leads to serious injury, and even if the patient is not a Medicaid recipient.
 
Medicaid fraud occurs when a provider intentionally:
  • Bills Medicaid for a service not actually provided to the patient.
  • Uses an improper procedure code to bill for a higher priced service when a lower priced service was provided.
  • Bills for non-covered services by describing the services as covered services.
  • Misrepresents a patient's diagnosis and symptoms and bills Medicaid for a service that is medically unnecessary.
  • Falsifies medical records.
  • Receives or gives an illegal kickback in return for referring a patient to a medical provider.
  • Falsifies a physician's certificate of medical necessity (COM) and bills Medicaid for services that require a COM.
  • Bills Medicaid for drugs dispensed without a lawful prescription.
  • Submits false time sheets for an employee of a home care provider, which causes the provider to bill for services not rendered.
 
Embezzlement Or Theft From a Patient
 
If a Medicaid funded facility or an employee of that facility steals money belonging to a resident, we can investigate, whether or not the resident receives Medicaid.
 
Commingling of Patient and Facility Funds
 
If a Medicaid funded facility willfully deposits a resident's funds into the facility's operating account for use by the facility, the money is commingled. Commingling makes the resident's funds available to pay the facility's operating expenses rather than the benefit of the resident. The MID investigates the commingling of funds of both Medicaid recipients and non-Medicaid residents in facilities that receive Medicaid funds.
 
Report Medicaid provider fraud to the Attorney General’s Medicaid Investigations Division at (919) 881-2320
 
Report recipient fraud to the state Division of Medical Assistance at 1-800-662-7030 or to your local county Department of Social Services.