How To Report Medicaid Fraud In Nc

Cases Of Medicaid Provider Fraud

As stated above in the Cases of Medicaid Recipient Fraud, provider fraud also comes in several different flavors. And again, is why both users and suppliers must work together to identify any fraudulent activity perpetrated by Medicaid suppliers.

Ways to assist the Office of Medicaid Management in identifying fraudulent activity include keeping records on the following items:

• When you received service from a Medicaid professional.
• Where the service took place.
• Who the professional was who provided care to you.
• Which services were given during the visit.
• Any additional services ordered by the provider.

Any services billed that werent actually provided are considered fraud and need to be reported.

Examples of Medicaid supplier fraud include:

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Red Springs Pharmacy Owner Pleads Guilty In Healthcare Fraud Scheme

NEW BERN, N.C. James Craig Bell, 63, pleaded guilty today to conspiracy to defraud Medicare, North Carolina Medicaid, and private health insurers through his pharmacy in Red Springs that operated under the name Townsends Pharmacy.

This defendant lined his own pockets with money intended to provide vital prescription drugs for the poor and disadvantaged, said U.S. Attorney Michael Easley. We will continue to investigate and prosecute shady schemes like this.

Submitting false and excessive claims to Medicare and Medicaid undermines the integrity of federal health care programs and wastes valuable taxpayer dollars, said Tamala E. Miles, Special Agent in Charge with the U.S. Department of Health and Human Services, Office of the Inspector General . HHS-OIG works tirelessly along with our law enforcement partners to hold accountable perpetrators of federal health care fraud.

Medications are expensive enough without pharmacy owners defrauding Medicaid and ripping off taxpayers, said Attorney General Josh Stein. These resources are meant to help people get the care and prescriptions they need. Im grateful for U.S. Attorney Easley and his offices partnership with my Medicaid Investigations team to hold accountable health care providers who waste these resources.

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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.

Reporting Medicare Fraud & Abuse

Medicare fraud and abuse can happen anywhere, and usually results in higher health care costs and taxes for everyone. Some examples include:

• A provider that bills Medicare for services or supplies they never gave you, like charging you for a visit you never had, or a back brace you never got.
• A provider that charges Medicare twice for a service or item that you only got once.
• A person who steals your Medicare number or card and uses it to submit fraudulent claims in your name.
• A company that offers you a Medicare drug plan that Medicare hasnt approved.

Remember:

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Preventing Fraud And Abuse

• Your Medicaid card and number are yours. Do not let anyone else use them.
• Do not give your Medicaid number to a stranger or in exchange for a special offer.
• Remember that Medicaid does not pay for mentoring, after-school programs, summer camps, or tutoring.
• Ask for a written description of the services offered to you.
• Do not agree to services that you do not think you or your child need.
• Do not sign a blank form.
• Write down the names of the people that provide your services, the agencies they work for, and the dates the services are provided.

Report Fraud Waste And Abuse

Unfortunately, there may be times when you see suspected fraud or abuse relating to Medicaid services.

If you suspect that someone is committing Medicaid fraud, report it. Examples of Medicaid fraud include:

• An individual who does not report all income or other health insurance when applying for Medicaid.
• An individual who does not get Medicaid uses a Medicaid member’s card with or without the member’s permission.
• A health provider or a clinic bills for services that were not provided or were not medically necessary.

You can report suspected fraud and abuse in any of the following ways:

• Call the AmeriHealth Caritas North Carolina Fraud, Waste and Abuse Hotline at 1-866-833-9718 or email .
• Call the Medicaid Fraud, Waste and Program Abuse Tip Line at 1-877-DMA-TIP1 .
• Call the State Auditor’s Waste Line at 1-800-730-TIPS .
• Call the U.S. Office of Inspector General’s Fraud Line at 1-800-HHS-TIPS .

Below are examples of information that will assist with the investigation:

• Contact Information .
• Description of the alleged fraudulent or abuse activities.
• Time frame of the allegation.
• Name and identification number of the suspected individual.
• Approximate dollar amounts involved, if known.
• Place of service.

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Reporting Medicaid Fraud And Abuse

You are encouraged to report matters involving fraud and abuse. If you want to report fraud or abuse, you can remain anonymous.

Medicaid fraud and abuse cost states billions of dollars every year, diverting funds that could otherwise be used for legitimate health care services.

Not only do fraud and abuse increase the cost of Medicaid without adding value, they increase risk and potential harm to people who are exposed to unnecessary services or procedures.

Cases Of Medicaid Recipient Fraud

Medicaid user fraud comes is a few different flavors and isnt always obvious. Thats why both providers and users need to be conscientious and work together to identify fraudulent activity. Examples of Medicaid user fraud include:

• The loaning of Medicaid ID cards to others.
• Changing or faking an order or prescription.
• Utilizing more than one Medicaid identification card.
• Deliberately getting conflicting, duplicate or excessive services and/or supplies.
• Selling supplies given by Medicaid to others, instead of using them yourself.

If you suspect that a recipient has engaged in any of the activities listed above or any other questionable activity, please call 1-877-87FRAUD. Your call will remain confidential.

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A Serious Crime: Public Assistance Fraud

Some people do not give important information or do not tell the truth when applying for help through their county Department of Social Services. Under North Carolina law, persons must give caseworkers all information needed to decide if they can receive benefits such as Work First Family Assistance, Food and Nutrition Services, Medicaid, Energy Assistance, Special and Emergency Assistance, and surplus commodities. Those who do not report correctly commit a crime. The crime–public assistance fraud–is committed when people get or try to get help by giving caseworkers false and incorrect information, or do not give information.

WHAT HAPPENS IF A PERSON IS FOUND GUILTY OF PUBLIC ASSISTANCE FRAUD?

A person found guilty of public assistance fraud can be fined, placed in jail, or both.

A person found guilty of Food and Nutrition Services fraud may get an even stiffer penalty. That penalty could include all of the above, and you may not be allowed to get Food and Nutrition Services for:

• 1st offense – 1 year

Reporting Fraud And Abuse

These examples of Medicaid fraud and abuse sound similar. Figuring out the difference between Medicaid fraud and abuse requires investigation. If you know or believe that Medicaid fraud or abuse is happening, please report it so it can be properly investigated. If you want to make a report, you can remain anonymous, but sometimes we may need to contact you in order to conduct an effective investigation. Your name will not be shared with anyone who is being investigated, but in rare cases involving legal proceedings we may have to reveal who you are.

Helpful information to include in a report:

• The name or names of the members.
• The name or names of the providers.
• The date or dates of the services.
• A description of the acts that you suspect involve Medicaid fraud or abuse.

How to report Medicaid fraud and abuse:

• Contact the Division of Medical Assistance by calling the DHHS Customer Service Center at 662-7030.
• Complete and submit a Medicaid fraud and abuse confidential online complaint form by going to the DHHS Customer Service website.

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Report Medicaid Fraud & Patient Abuse

Report Medicaid provider fraud or patient abuse to the Attorney Generals Medicaid Investigations Division at 881-2320. You can also report fraud or abuse online HERE.

Fraud by Medicaid recipients such as fraudulent eligibility or transfer of assets should be reported to the North Carolina Division of Health Benefits or to your Local County Department of Social Services.

How You Can Help In The Fight Against Medicaid Fraud

Medicaid Fraud ends up costing us all in the form of higher insurance premiums and taxes. Heres what you can do to help fight Medicaid Scams.

• Review your Medicaid bill when you receive it. Did you receive each service and all supplies listed on the invoice? Are the dates correct?
• Only give your Medicaid number to those needing it.
• Dont lend your Medicaid card to anyone. If anyone uses it in your name they are committing a crime.
• Never request medical services or equipment you dont need.
• Dont sign blank forms for medical services or equipment.
• Request and retain copies of anything you sign.
• Only share Medicaid and your medical information with those needing it.
• Be wary of offers for free testing and medical screenings, especially when the services are covered by Medicaid.
• Never give out your Medicaid information to telemarketers or door-to-door salesmen pushing free medical services or equipment. Why would they need your Medicaid number?
• Only supply those youve received medical care or services from access to your Medicaid ID card.
• Never let medical providers bill Medicaid for services before contacting you.
• Ignore fantastic claims made about Medicaid paying for medical care or services everyone knows they dont cover.

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Cashing In On The Dead: Former Nc Couple Lived Lavishly On Medicaid Fraud Money

A former North Carolina couple facing prison time for Medicaid fraud flaunted the fruits of their crimes on social media.

RALEIGH, N.C.

On his Facebook page, Timothy Mark Harron describes himself as an “Entrepreneur, author, husband, traveler, jet setter, wine connoisseur and lover of fine food.”

On her page, his wife, Latisha Harron, uses the motto Let your dreams be bigger than your excuses.

For years, the couple lived a dream, traveling to Australia, the South Pacific, Malibu, Napa, Italy and other destinations. Tim Harron routinely posted selfie videos at the resorts or penthouses where the couple vacationed. Over a three- to four-year period, they were true jet-setters in their private $900,000 plane.

“Were often dealing with crimes that are victimless or seen as victimless,” said Thomas Dearden, an assistant sociology professor at Virginia Tech, who studies white-collar criminals.

Dearden said the online lifestyle flaunting was essentially a digital trophy case for the Harrons.

“Those kind of social media posts are their own reward and kind of validation,” he said.

Dave Richard, who oversees North Carolina’s Medicaid program, which provides health care to low-income children and adults, finds only aggravation in the posts.

“Its these kinds of things that are just infuriating,” Richard said, noting that cases of fraud tarnish the good work of real service providers.

The fraudulent billing accelerated from there.

New? Maybe. Illegal? Definitely.

Attorney General Josh Stein Announces $13 Million Medicaid Fraud Conviction

For Immediate Release:

Contact:Laura Brewer 716-6484

Attorney General Josh Stein today announced that Timothy Mark Harron of Las Vegas, Nevada, pleaded guilty to conspiracy to commit health care fraud and wire fraud, conspiracy to commit money laundering, and aggravated identity theft. He further agreed to forfeit the proceeds of his crimes, which in addition to cash include a private jet, a sports car, a pickup truck, real estate in eastern North Carolina, and hundreds of thousands of dollars in designer jewelry, clothing, and luxury items seized from his penthouse condominium.

This person stole and used the information of people who had died to defraud the Medicaid program, and then used that money to fund an extravagant lifestyle, said Attorney General Josh Stein. Im grateful to all of our state and federal partners for their work on this case. My office will continue to hold accountable those who waste taxpayer money and cheat Medicaid.

Harron admitted to conspiring with his wife, Latisha Harron, to defraud the North Carolina Medicaid program by billing the government for fictitious home health services and laundering the proceeds of the fraud into, among other things, a British Aerospace Bae 125-800A Aircraft, a 2017 Aston Martin DB 11 sports car, a 2016 Ford F-150 Super-Crew pickup truck, and properties in Ahoskie and Rich Square, North Carolina.

About the Medicaid Investigations Division

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What Can You Do About Health Care Fraud

If you think a provider, member, or other personis misusing Medicaid benefits, please tell us right away. We will take your call seriously.

To report potential fraud, waste, or abuse to Carolina Complete Health, please contact us right away. You do not need to give your name.

• Call Member Services at

To report waste, abuse, or fraud, gather as much information as possible.

When reporting about a provider include the following if you can:

• Name, address, and phone number of provider
• Name and address of the facility
• Type of provider
• Names and phone numbers of other witnesses who can help in the investigation
• Dates of events

When reporting about someone who gets benefits, please include:

• The persons name
• The persons date of birth, Social Security Number, or case number if you have it
• The city where the person lives
• Specific details about the waste, abuse, or fraud

What Medicaid Fraud Does

Medicaid Fraud has far-reaching effects that touch almost everyone whether its the people in need of health care, honest providers of health care and then finally you the taxpayer. Every time a patient files a claim fraudulently and each time a provider bills more than they should they are taking money away from those that need it.

If you know anyone defrauding the Medicaid system you must report it immediately. Below are many forms of Medicaid abuse that you should be on the lookout for.

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Gaston County Public Assistance Program Integrity Program

For more than 20 years, Gaston County has employed program integrity workers, who are responsible for investigating allegations of fraud and misuse of benefits in the following programs:

• Food and Nutrition Services , which provides food and electronic vouchers to buy food from authorized retailers, often referred to as “food stamps”
• AFDC/TANF , which offer cash benefits, often referred to as “welfare”
• Medicaid, which provides health benefits to low-income individuals without insurance

Gaston’s program integrity workers respond to complaints of suspected fraud by examining records for overpayment, or clients who receive more services/funds than warranted. Overpayment is usually due to client error or oversight – such as failing to report an increase in income – or staff/clerical error. Less than 6% of overpayments in Gaston County meet state and federal guidelines for intentional fraud.

When program integrity workers discover overpayment, they work to recoup that money from clients. When intentional fraud is suspected, staff work with the Gaston County District Attorney and Gaston County Police Department, which open criminal investigations and, where appropriate, pursue charges.

If you suspect someone is committing fraud with one of these services, or obtaining one of these benefits through fraudulent means, please call our Program Integrity Hotline at 704-862-7550.

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.

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Reporting Suspected Medicaid Fraud Waste And Abuse

Office of Compliance and Program Integrity

This article assists providers to identify and report potential report fraud, waste, or abuse.

The Office of Compliance and Program Integritys mission is:

• To protect the resources of the Division of Health Benefits by reducing or eliminating fraud, waste, and abuse of providers and beneficiaries in the NC Medicaid Program.

The terms fraud, waste and abuse are defined as follows:

• Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefits to himself or some other person.
• Waste: Costs that could have been avoided without a negative impact on quality.
• Abuse: Occurs when provider practices are inconsistent with sound fiscal, business, or medical practices, and results in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health.

Any matters involving potential or suspected Medicaid fraud, waste, or abuse shall be reported to the Office of Compliance and Program Integrity. Individuals may remain anonymous however, sometimes to conduct an effective investigation, staff may need to contact individuals. Individual name will not be shared with anyone investigated except in some rare cases involving legal proceedings.

Examples of Medicaid fraud and abuse:

Office of Compliance and Program IntegrityDHB, 919-527-7749