Medicaid Provider Fraud and Patient Abuse

Report Medicaid Fraud & Patient Abuse

Report Medicaid provider fraud or patient abuse to the Attorney General’s Medicaid Investigations Division at (919) 881-2320. You can also report fraud or abuse online HERE.

Fraud by Medicaid recipients (fraud by those being served by Medicaid) such as fraudulent eligibility or transfer of assets should be reported to the North Carolina Division of Health Benefits (at 1-800-662-7030 or online HERE) or to your Local County Department of Social Services.

Medicaid Investigations Division

The Medicaid Investigations Division (MID) investigates:

• Fraud by Medicaid health care providers or suppliers;
• Physical abuse of Medicaid patients or any patient in a Medicaid-funded facility;
• Stealing or improper commingling of patients’ funds in a Medicaid-funded facility.

MID is staffed by Department of Justice attorneys, investigators, and auditors trained in the complexities of health care fraud investigation and litigation.

We work closely with United States Attorneys, District Attorneys, Federal and State law enforcement agencies, managed care organizations, and private insurance company fraud units.

Our investigations can result in criminal charges against health care providers, as well as civil actions to recover overpayments, treble damages, and civil penalties.

MID has recovered over $900 million for the Medicaid program and obtained over 450 criminal convictions in fraud and abuse cases.

Types of Cases

Medicaid Fraud

Medicaid Fraud occurs when a Medicaid provider or supplier knowingly:

• Bills Medicaid for a service or product not actually provided to the patient
• Uses an improper code to bill Medicaid for a higher priced service or product when a lower priced service or product was provided
• Bills Medicaid for non-covered services by describing them as covered services
• Misrepresents a patient’s diagnosis or condition and/or bills Medicaid for a service or product that is not medically necessary
• Falsifies medical records or supporting documentation
• Receives or gives a kickback (money or some other thing of value) for referral of a Medicaid patient for medical services or products
• Falsifies a physician’s certificate of medical necessity
• Bills Medicaid for drugs dispensed without a lawful prescription
• Creates false employee time sheets and bills Medicaid for services not rendered

Physical Abuse of a Patient

When any provider or employee of a Medicaid-funded facility (i.e., nursing home, rest home, or state hospital) physically assaults any resident, MID can investigate. We investigate abuse whether or not it leads to serious injury, and even if the patient is not a Medicaid recipient.  We also investigate physical abuse of Medicaid patients by caregivers in settings other than nursing homes.

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, even if the resident is not a Medicaid recipient.

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,” and the resident’s funds are available to pay the facility’s operating expenses rather than to benefit the resident. We investigate the commingling of funds of both Medicaid recipients and non-Medicaid residents in facilities that receive Medicaid funds.

Signs of Medicaid Fraud & Abuse

Fraud

• The provider bills Medicaid for, or the patient is pressured to receive, unnecessary or excessive services, products, or tests.
• The provider bills Medicaid for services, products, or tests not documented in a patient’s file.
• The provider alters or fabricates a patient’s medical records or other supporting documentation.
• The provider claims to provide services, products, or tests for free.

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 of the resident’s personal spending.
• The facility does not maintain residents’ personal funds in a bank account separate from the facility’s operating account. (Note that the residents’ funds may be kept together in one bank account.)
• The ending balance in the facility’s ledger showing the residents’ personal 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.
• Funds are spent to purchase items of no use to the resident.

Reporting Medicaid Fraud & Abuse

Why Report Medicaid Fraud & Abuse?

Medicaid fraud should be reported because Medicaid payments are made from taxpayer funds. When Medicaid funds are fraudulently taken or stolen, that money is no longer available to help deserving patients: it cheats both recipients and taxpayers.

Patient abuse and the stealing or commingling of Medicaid recipient funds should be reported because it exploits our most vulnerable adults.

Criminal convictions can deter fraud and abuse. Civil lawsuits can recover money that can be returned to the Medicaid program to help recipients.

Which People Or Companies Do I Report?

Report any Medicaid provider you suspect has committed fraud or abuse. A Medicaid provider includes any individual, corporation, or other entity paid by Medicaid for providing a health care service. It also includes their officers and employees.

Medicaid providers can include: adult care homes, ambulance and transportation companies, behavioral healthcare providers, chiropractors, community care service providers, dentists, home health agencies, hospitals, laboratories, medical equipment and supplies companies, nurses, nurse aides, nursing homes, pharmaceutical companies, pharmacies, physicians, physical therapists, podiatrists, psychiatrists, psychologists, social workers, speech therapists, and others.

Is There Protection for Whistleblowers?

State and Federal laws provide protection to employees who report fraud or abuse.

Any employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against by his or her employer for reporting fraud is entitled to relief, including job reinstatement, twice the amount of back pay, and compensation for any court costs and attorneys’ fees.

Where to Report Fraud & Abuse

Report Medicaid provider fraud or patient abuse to the Attorney General’s Medicaid Investigations Division at (919) 881-2320. You can also report fraud or abuse online HERE.

Medicaid recipient fraud (fraud by those being served by Medicaid, including fraudulent eligibility and transfer of assets) should be reported to the state Division of Medical Assistance by filing a complaint or by calling 1-800-662-7030. You can also report Medicaid recipient fraud to your local county Department of Social Services.

To report Medicare fraud, contact the Office of Inspector General, US Department of Health and Human Services, at (800) 447-8477.

North Carolinians with information about Medicare error, fraud and abuse can also contact the North Carolina Senior Medicare Patrol Program at (855) 408-1212.

To report private insurance fraud, contact the NC Department of Insurance or call the department at (888) 680-7684.

To report fraud and abuse in state licensed facilities, agencies and nursing homes, contact the North Carolina Division of Health Service Regulation.