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OCPI/Fraud Waste and Abuse

You are encouraged to report matters involving Medicaid fraud and abuse. You may remain anonymous; however, sometimes to conduct an effective investigation, staff may need to contact you. Your name will not be shared with anyone investigated. In rare cases involving legal proceedings, your name may need to be revealed.

Medicaid fraud and abuse is when a person knowingly cheats or is dishonest, resulting in a benefit such as payment or coverage.

Examples of Medicaid fraud and abuse:

  • An individual does not report all income when applying for Medicaid
  • An individual does not report other insurance when applying for Medicaid
  • A non-recipient uses a recipient's card with or without the recipient's knowledge
  • 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

Reporting Options

DHHS Customer Service Center
Phone: 800-662-7030 (English or Spanish)
Online Confidential Complaint Form

Medicaid Fraud, Waste and Program Abuse Tip-Line
Phone: 877-DMA-TIP1 (877-362-8471)

Health Care Financing Administration, Office of Inspector General Fraud Line
Phone: 800-HHS-TIPS

State Auditor Waste Line
Phone: 800-730-TIPS

County Department of Social Services (DSS) (link is external)

False Claims Act (link is external)

Section 6023 of the Deficit Reduction Act of 2005 requires providers receiving Medicaid payments to educate employees, contractors, and agents about federal and state fraud and false claims laws, and the whistleblower protections available under those laws.

Self Audit

NC Medicaid recommends providers conduct periodic, voluntary self-audits to identify instances where services reimbursed by Medicaid or Health Choice are not in compliance with program requirements. Self-auditing is a critical component which can mitigate potential risks and facilitate resolution of matters that potentially violate state or federal administative rules, regulation or policy governing Medicaid and Health Choice. This includes matters exclusively involving overpayments or erros that do not suggest violations of law.  

Excluded Providers

An excluded provider is an individual or entity that cannot bill or cause services to be billed to Medicare, Medicaid or NC Health Choice. DHHS works diligently to prevent excluded providers from participating in NC Medicaid and NC Health Choice to comply with federal regulations.

Visit the Excluded Provider web page to learn more and see the Excluded Provider list.

Medicaid Integrity Program Provider Audit (link is external)

The Deficit Reduction Act of 2005 created the Medicaid Integrity Program. The Act directed the Centers for Medicare and Medicaid Services to provide effective support and assistance to states to combat Medicaid provider fraud and abuse.

Payment Error Rate Management (link is external)

To comply with the Improper Payments Information Act of 2002, the Centers for Medicare and Medicaid Services implemented a Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the State Children’s Health Insurance Program (SCHIP). 

Contact

NC Medicaid Operations Section
Phone: 919-814-0181
Fax: 919-814-0036