Learn How To Recognize Report And Protect Yourself From Health Care Fraud And Abuse
Health care fraud and abuse refers to deceptive practices in the health industry that lead to undeserved profit. These schemes cost the nation billions of dollars each year and result in higher health insurance premiums and out-of-pocket expenses for consumers.
Health care fraud is a deliberate deception or misrepresentation of services that results in an unauthorized reimbursement.
Health care abuse refers to practices that are inconsistent with accepted medical, business, or fiscal practices.
These practices can take many forms, the most common including:
The Consumer Protection Division of the Office of the Attorney General aims to help educate consumers on how to recognize fraud and abuse and how to file a complaint with the appropriate agency.
Other State Fraud And Abuse
Unrelated to Medicaid program operations or processes, a hotline exists to provide citizens the capability to report other types of fraud, waste and abuse related to the agency of DMAS. These complaints are taken very seriously, and the information a caller provides is screened by the Office of the State Inspector General to determine if it is sufficient and significant enough to conduct an effective investigation. It is important to provide specific details in order to conduct an investigation. Examples of these types of complaints are as follows:
- Embezzlement or other fraudulent conduct
- Contract fraud
- Inappropriate use of state funds
- Falsification of documents
- Abuse of state owned property, including personal use
OSIG administers the Hotline related to these types of allegations and will conduct and coordinate an investigation in partnership with appropriate individuals at the state agency. These types of allegations should be reported to the Office of the State Inspector General using the link listed below. You can find more information on the reporting process using the OSIG State Fraud and Abuse Hotline information sheet.
Who Investigates Medicare Fraud
Medicare fraud may be investigated by a handful of government agencies including the U.S. Department of Justice, the U.S. Department of Health and Human Services , the HHS Office of Inspector General and the Centers for Medicare and Medicaid Services.
Medicare fraud can lead to imprisonment, fines and penalties, with both criminal and civil liability.
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How To Report Fraud
You can help protect your tax dollars by reporting suspected fraud by phone, through the Internet or by regular mail. You can do this without giving your name, but if you agree to give your name and other contact information, that helps the investigators to obtain future information.
Before you make a report, try to get as much information as possible, including:
- the name of the person you suspect of committing fraud. This might be a person receiving medical benefits or a health care professional hospital, nursing home, or other facility that provides Medicaid services
- the Medicaid ID number
- the amount of money involved, and/or
- a description of the acts that you suspect involve fraud
What To Report To Us
Let us know if you think someone has charged for a medical service or medicine you didnt receive.
We accept tip-offs about:
- doctors, pharmacists, dentists and allied health professionals such as physiotherapists
- pharmacies, medical practices, hospitals and administrative staff.
The kinds of payment concerns to report to us include:
- Payments for through incentive programs including the Practice Incentive Program and Workforce Incentive Program .
- COVID-19 vaccination issues related to the charging of out of pocket costs, or the billing of additional Medicare items in general practice.
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What Is Considered Medicare Fraud
- The more tests that are done, the less you pay out-of-pocket
- Offers you a gift to get you to use their services
- Waives a copayment or says the co-payment is higher on a no-copay plan
- States you can receive coverage on a non-covered service
- The service or product Medicare endorses
If you have Medicare, you can look through your Medicare Summary Notice and compare your statements and receipts from your providers.
So, you noticed a bill for a product or service not applicable. Contact the office to be sure of the mistake. If an error occurred, thats Medicare abuse.
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.
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Report Fraud Waste & Abuse
- Issue of concern
- All other pertinent information
Your report may be anonymous however, if you do not provide your name, we will not be able to call you back for more information. Your message will be kept confidential to the extent permitted by law.
You may also report fraud, waste or abuse directly to the state of Ohio by using one of the methods below:
- Ohio Department of Medicaid : Call 1-614-466-0722 or visit the Ohio Department of Medicaid Reporting Suspected Medicaid Fraud page.
- Medicaid Fraud Control Unit : Call 1-800-642-2873 or visit the Ohio Attorney General Report Medicaid Fraud page.
- Ohio Auditor of State : Call 1-866-FRAUD-OH or email
Thank you for your assistance in keeping fraud, waste and abuse out of health care.
Please see the Program Integrity and Investigations Department Recovery Process to learn more about how CareSource manages fraud, waste and abuse recoveries.
CareSource is required to provide you with information on the False Claims Act, please see details below.
How To Submit A Tip
You dont have to give us your details when you submit a tip-off.
But it helps if you do, so we can contact you for more information if we need it.
If you want to make a report, use our tip-off form.
Or, if you cant use the webform, call our hotline:
Provider Benefits Integrity Hotline
If you have concerns relating to a health provider you can submit details to the department online by completing the tip-off form or by calling the dedicated hotline between the hours of 9am to 5pm AEST.
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Pursue Whistleblower Rewards Through A Fca Claim
A second, more lucrative option for obtaining rewards through reporting Medicare fraud is to bring a False Claims Act claim directly against the offending individuals and/or organizations who perpetrated the fraud. In an FCA claim, a whistleblower files a suit through his or her attorney against the offending parties, and the federal government then has the option of joining in your claim. If you are able to provide information to the government which brings about a successful FCA claim, then you as the whistleblower are eligible for a reward of up to 30% of the governments total recovery. Given the massive amounts of Medicare fraud that occur, this number could be quite substantial, even in the millions.
When you first file an FCA claim, it is often possible for you as the whistleblower to remain anonymous while the government determines whether to proceed with the matter. At a later point, however, your anonymity may be lost, but if you are eligible for large rewards and can help the government stop wrongdoers from perpetuating fraud on you and your fellow taxpayers, you may decide revealing your identity is worth it.
Why It Is Important
The Medicaid program is funded with both state and federal tax dollars. It is designed to pay for health care for low-income and vulnerable Floridians who need care. When people get benefits they dont deserve, or when providers are paid for services that were not supplied, it wastes your tax dollars and takes services away from those who need them.
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Where To Report Fraud & 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.
Medicaid recipient fraud 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 447-8477.
North Carolinians with information about Medicare error, fraud and abuse can also contact the North Carolina Senior Medicare Patrol Program at 408-1212.
To report private insurance fraud, contact the NC Department of Insurance or call the department at 680-7684.
To report fraud and abuse in state licensed facilities, agencies and nursing homes, contact the North Carolina Division of Health Service Regulation.
How To Report Medicare Fraud
You can call the Medicare fraud hotline or report the fraud by contacting one of these organizations:
- Department of Health and Human Services Office of Inspector General Medicare fraud hotline at 1-800-HHS-TIPS
- Contact the HHS by mail at HHS Tips Hotline, PO Box 23489, Washington, DC 20026-348
- Centers for Medicare and Medicaid Services at 1-800-MEDICARE
- Contact CMS by mail at Medicare Beneficiary Contact Center, PO Box 39, Lawrence, KS 66044
- You can report it by calling the CMS report hotline or submit the information online.
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Consult With A Seasoned Medicare Fraud Attorney
At Kreindler & Associates, we understand that the decision to become a whistleblower is not an easy one. The government relies on courageous insiders like you to come forward with information that can stop harmful Medicare fraud. Our experienced healthcare fraud attorneys will work with you every step of the way to determine your appropriate course of action, protect you from retaliation, and collect your much-deserved reward. If you suspect that someone is committing Medicare fraud, contact us today for an evaluation of your allegations.
Can You Go To Jail For Medicaid Fraud
All of these activities are against the law, and there are potentially serious consequences for engaging in any of them. The minimum consequence for fraudulent claims may be the denial of payment. Medicaid may also suspend or revoke authorization to bill for a provider suspected of fraud, and it may sue in a civil court to recover fraudulently claimed benefits. Serious cases of suspected fraud may also be referred to a prosecutors office for criminal charges, which may result in prison time for convicted fraud participants.
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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.
What Is Medicaid Fraud
There are many types of Medicaid provider billing fraud. Fraud can include providers billing Medicaid for goods and services that were never provided, were of lower quality or were unnecessary.
The Oregon Department of Justices Medicaid Fraud Control Unit aggressively investigates and prosecutes billing fraud committed by Medicaid providers, and abuse and neglect of residents who live in Medicaid-funded facilities. These complex cases can take years to investigate, but bring millions of dollars back to the state Medicaid program.
Medicaid recipient fraud can include falsifying information on applications in order to receive benefits, which would be investigated by the DHS Fraud Unit. The MFCU does not investigate individuals who receive services as part of the Medicaid program.
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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.
Medicaid Program Integrity Education
The Center for Program Integrity provides educational resources to educate providers, beneficiaries and other stakeholders in promoting best practices and awareness of Medicaid fraud, waste and abuse.
Medicaid Provider Integrity Education materials are applicable to providers, beneficiaries, and state managed care plans. MPIE materials include topic-based information in an easy-to-read format that aid in furthering education efforts of providers, beneficiaries and other Medicaid stakeholders. The information provided is intended to further the education efforts of Medicaid Program Integrity Education, assist providers with being in compliance with their billing and assist in the fight against fraud, waste and abuse.
To access educational booklets, fact sheets and provider checklist resources and tools which promote efforts to prevent Medicaid fraud, waste and improper payments, visit the Medicaid Program Integrity Education page on the Centers for Medicare and Medicaid Services website.
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Who Investigates Medicaid Fraud
All 50 states, plus the District of Columbia, Puerto Rico and U.S. Virgin Islands, operate their own Medicaid Fraud Control Units . These MFCUs are charged with taking reports from the public, reviewing billing decisions and invoices, inspecting facilities for fraud, waste and abuse, and referring suspected fraud cases to the authorities. Most MFCUs also investigate claims of abusive care of Medicaid beneficiaries, such as in nursing homes and other live-in facilities.
Submit A Hotline Complaint
OIG Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services programs. Every report we receive is important, however, not every submission results in an investigation. Due to the high volume of complaints we receive, it is not possible to contact every complainant. However, Hotline tips are incredibly valuable, and we appreciate your efforts to help us stamp out fraud, waste, and abuse.
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Cms Efforts To Stop Fraud Waste And Abuse
Medicare creates the Program Integrity Enhancements to the Provider Enrollment Process rule to end fraud, waste, and abuse. Basically, Medicare expects providers and suppliers to meet specific standards to remain in the Medicare program.
Program rules include providers and suppliers:
- Are unable to come back into the program under a different name
- Cant bill from a non-compliant location
- No outstanding overpayment debts to Medicare
- Cant abuse ordering of Part A, B, or D items
Applicants that submit false or misleading information risk being unable to participate in the Medicare program for up to 3 years. CMS has the ability to block up to 10 years. Second-time offenders can expect up to 20 years ban from the Medicare program. CMS hopes these measures will prevent bad actors from stealing tax dollars. In addition to the new rules, CMS is working hard on transparency initiatives.
If You See A Name You Don’t Know On Your Medicare Statement
Most of us recognise our doctors name, so its not unusual to be concerned if you see a name you dont recognise on your Medicare statement.
If this happens, consider whether you might have had a service, such as an eye test, pathology, or diagnostic imaging, from someone other than your usual provider.
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How To Spot Medicaid Fraud
Medicaid recipients, or their family members and people who work for them, should closely monitor medical billing statements. Keep a lookout for unusual activity, such as:
- charges for services that were never performed, or for goods you never received.
- billing for the same thing twice.
- services that were not ordered by your doctor.
- providers who recommend/perform unnecessary services or tests.
Medicaid fraud may also include:
- a patient whose medication is missing.
- unexplained cuts, black eyes, bruises or burns.
What Is Considered Medicare Abuse
Abuse can be found when billing for unnecessary services or services that arent medically necessary occur. If youre overcharged for services or supplies, then youre a victim of Medicare abuse. However, if a provider misuses billing codes to increase reimbursement, the doctor commits Medicare abuse.
Medicare wont use your name during the investigation of Medicare fraud, waste, or abuse if you dont want them to, you can remain anonymous.
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What Documents Do I Need To Report Medicare Fraud
If youre reporting Medicare fraud, its helpful to have some of your information ready.
- Medicare number
- Information about the service that was supposedly provided
- and the reason you think fraud was committed
If a reported Medicare fraud leads to the recovery of funds, Medicare may provide a reward. If you or someone you know suspects fraud, waste, or abuse, report it immediately.
The Center for Medicare and Medicaid Services states that Medicare fraud is:
- Intentionally billing Medicare for a service not provided
- Billing Medicare at a higher rate
- If a provider pays for referrals of Medicare beneficiaries
Medicare fraud is severe its not human error, its highly illegal, and it involves doctors or beneficiaries abusing the system for their own benefit. Report Medicare fraud as soon as possible.
Medicaid Fraud: How To Detect And Report Fraud
- Do you suspect a person or medical provider of unethical billing practices? Learn how to report Medicaid fraud to the appropriate authorities in your area.
Medicaid fraud is a major problem in the United States. Each year, according to the U.S. Centers for Medicare & Medicaid Services , nearly 15% of payments are processed improperly, usually for fraudulent reasons, which imposes a direct cost to taxpayers of more than $57 billion.
Aside from the direct costs of improper payments, Medicaid fraud drives up the cost of coverage for all beneficiaries, reduces the efficiency of the billing process and diverts resources toward investigations and prosecutions of suspected cases. Better knowledge among the public of how to report Medicaid fraud has the greatest potential to reduce these wasted resources.
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