The goal of the NC Medicaid Office of Compliance and Program Integrity (OCPI) is to stop fraud, waste and abuse in Medicaid.
Report Medicaid Fraud and Abuse
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
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, Waste and Program Abuse Tipline
Phone: 877-DMA-TIP1 (877-362-8471)
Health Care Financing Administration, Office of Inspector General Fraud Line
Phone: 800-HHS-TIPS (800-447-8477)
State Auditor Waste Tipline
Phone: 800-730-TIPS (800-730-8477)
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.
NC Medicaid recommends providers conduct periodic, voluntary self-audits to identify instances where services reimbursed by Medicaid 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 administrative rules, regulation or policy governing Medicaid. This includes matters exclusively involving overpayments or errors that do not suggest violations of law.
An excluded provider is an individual or entity that cannot bill or cause services to be billed to Medicare or Medicaid. NCDHHS works diligently to prevent excluded providers from participating in NC Medicaid to comply with federal regulations.
Visit the Excluded Provider webpage to learn more and see the Excluded Provider list.
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.
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 NC Medicaid program.
Education sessions hosted by the NC Medicaid Dental Policy Team and the Office of Compliance & Program Integrity The session included updates in dental policy, an overview of the role of OCPI, a review of the dental post payment program and the process of pre-payment.
Office of Compliance and Program Integrity
This page was last modified on 02/12/2024