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Fraud and Abuse

What are fraud and abuse?

The Centers for Medicare & Medicaid Services (CMS) defines fraud as any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in an unauthorized benefit for themselves or some other person. It also includes any act that constitutes fraud under applicable state or federal law.

CMS defines abuse as any provider practices that are inconsistent with sound fiscal, business, or medical practice, and result in unnecessary cost to the Medical Assistance (MA) program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

Examples of fraud and abuse by providers:

  • Billing more than once for the same service.
  • Billing one family therapy session held with several members as several hours of individual therapy.
  • Billing or charging MA recipients for covered services.
  • Dispensing generic drugs and billing for brand name drugs.
  • Failure to complete clinical medical record documentation.
  • Falsification or back dating of clinical record entries.
  • Falsifying information on their enrollment form.
  • Falsifying records.
  • Performing inappropriate or unnecessary services.

Indicators of fraud and abuse by behavioral health providers:

  • When members are asked to sign blank encounter forms.
  • When one provider frequently attends routine physical health or behavioral health with a member that is held by a different service provider.
  • When providers make frequent unscheduled visits to a member’s home and/ or spend the majority of the time discussing topics unrelated to the treatment or service plan.
  • When the provider does paperwork during session time and does not work directly with the member or their family.
  • When the provider is frequently late or leaves earlier than the scheduled appointment.

Examples of fraud and abuse by members:

  • Falsifying information on their enrollment form.
  • Requesting medical care that is not needed.
  • Seeking drugs or services that members do not need.
  • Sharing a Medicaid card with another so a non-member can receive services.

Indicators of fraud and abuse by members:

  • Not being able to prove their identify.
  • Requesting services or medication that the member feels may not be medically needed.
  • Using more than one Social Security number or name.

How to report an allegation of fraud, waste, or abuse:

  • Department of Human Services Fraud Hotline: 1-866-379-8477online, or by email.
  • AmeriHealth Caritas tips hotline: 1-866-833-9718.

All reports may be made anonymously.