Author: 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 Integrity’s 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:
- A provider’s credentials are not accurate
- A provider bills for services that were not rendered
- A provider performs and bills for services not medically necessary
- A provider upcodes procedures to receive higher reimbursement
- An individual does not report all income when applying for Medicaid
- An individual does not report other insurance when applying for Medicaid
- A non-beneficiary uses a beneficiary’s card with or without the recipient's knowledge
People may report a complaint by calling Medicaid Fraud, Waste and Program Abuse Tip-Line at 919-814-0181, or completing an Online Confidential Complaint Form.
Office of Compliance and Program Integrity
DHB, 919-527-7749