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Medicaid Investigations Division

The MID handles the following types of cases:

  • Fraud committed by Medicaid health care providers;
  • Physical abuse of Medicaid patients and of patients in Medicaid-funded facilities;
  • Embezzlement, theft, and improper commingling of patients’ funds in Medicaid-funded facilities.

Our Medicaid Investigations Division (MID) is staffed by Department of Justice attorneys, investigators and auditors trained in the complexities of health care fraud litigation.

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, 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.

Over the past decade, the NC MID has recovered more than $850 million in illegally obtained money and helped win more than 450 criminal convictions in health care fraud and abuse cases.

Types of Cases

Medicaid Fraud

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, letting the provider bill 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, the MID can investigate. We investigate abuse whether or not it leads to serious injury, and even if the patient is not a Medicaid recipient.

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 to benefit the resident.

The MID investigates the commingling of funds of both Medicaid recipients and non-Medicaid residents in facilities that receive Medicaid funds.

Signs of Medicaid Fraud & Abuse

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. (Note that the 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 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.

Reporting Medicaid Fraud & Abuse

What is Medicaid?

Medicaid is a state-administered program established by Title Nineteen of the Social Security Act and funded by federal, state, and county funds. It provides medical assistance to qualifying low-income individuals and families.

Medicaid is overseen by the United States Department of Health and Human Services and administered in North Carolina by the North Carolina Department of Human Services, Division of Medical Assistance.

Why Report Medicaid Fraud & Abuse?

Patient abuse and the embezzlement, theft, and commingling of Medicaid funds should be reported because they exploit our most vulnerable elderly adults.

Medicaid fraud should be reported because Medicaid payments are made from federal, state, and county funds supplied by taxpayers. When Medicaid funds are lost or stolen through fraud, that money is no longer available to help deserving patients.

Medicaid fraud should be reported because it cheats both recipients and taxpayers. Criminal convictions can deter fraud and abuse. Civil suits can also recover money that can be returned to the Medicaid program to help patients.

Which People Or Companies Do I Report?

Report the Medicaid providers whom you suspect have 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:  ambulance and transportation companies, chiropractors, community care service providers, dentists, home health agencies, hospitals, laboratories, medical equipment companies, nurses, nurse aides, nursing homes, adult care homes, pharmacies, physicians, physical therapists, podiatrists, 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.

Federal law provides that whistleblowers who qualify can file a civil false claims act action in federal court under 31 U.S.C. § 3729 and be awarded a percentage of the proceeds of the action or settlement. Whistleblowers should seek the advice of an attorney to determine whether they qualify.

Where to Report Fraud & Abuse

You can report Medicaid provider fraud or abuse to the Attorney General’s Medicaid Investigations Division at (919) 881-2320. The NC Department of Justice’s Medicaid Investigations Unit is located at 5505 Creedmoor Rd., Suite 300, Raleigh, N.C. 27612. Our fax number is (919) 571-4837. You can also report fraud or abuse using our online Fraud Reporting Tool.

Medicaid recipient fraud (fraud committed 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.

To report serious health care fraud, contact the Federal Bureau of Investigation.

Research pre-employment verification for health care workers at the Health Care Personnel Registry or call the Registry’s 24-hour automated telephone voice response system at (919) 715-0562.

To find related rules, visit the Centers for Medicare and Medicaid Services.

1-877-5-NO-SCAM (1-877-566-7226) (919) 716-6000