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How to Spot Medicaid Fraud & Abuse

Be alert to possible signs of fraud or abuse, including:
Physical Abuse
  • The resident has bruises, welts, lacerations, broken bones or burns.
  • The resident's injuries are inconsistent with the explanation of the injuries.
  • The resident develops a significant unexplained change in behavior and becomes fearful, mistrustful, withdrawn, or agitated.
Financial Abuse
  • The facility does not maintain a ledger, either in paper or electronic form, that shows information about the resident's personal spending.
  • The facility does not maintain the personal funds of residents in a bank account that is separate from the facility's operating account (however, the funds of all residents may be kept together in one bank account).
  • The ending balance in the facility's ledger showing the residents' personal funds spending does not match the ending balance in the bank statement for the residents' personal funds bank account.
  • Large sums of money are withdrawn without the resident's knowledge.
  • Checks are written or sums withdrawn for the purchase of items that would be of no use to the resident.
Health Care Fraud
  • The patient is pressured to receive unnecessary or excessive services.
  • The patient's medical records are altered.
  • The medical provider claims to provide services for free.
  • The medical provider dispenses excessive amounts of controlled substances.

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.