Report Medicaid Provider Fraud
Fraud and abuse of public programs affects all of us. Everyone can take responsibility to report fraud and abuse. There are three ways to report fraud and abuse of taxpayer money:
- Call toll free: 1-208-334-5754
- E-mail a fraud complaint to: prvfraud@dhw.idaho.gov
- US Mail or Fax, Complete Provider fraud complaint form and send to:
Fax a complaint form to 1-208-334-2026 or
Mail to: Medicaid Fraud and Program Integrity Unit, P. O. Box 83720, Boise, ID 83720-0036
If you are filling out a form, provide us with as much detail as possible and a contact name, phone number or e-mail address. This will help us if we have additional questions regarding the information you submit.
Together we can ensure taxpayer money is used for people who really need help.
Fraud and abuse significantly impact the Medicaid program by using up valuable dollars necessary to help vulnerable children and adults access health care.
Medicaid fraud and abuse are actively pursued by the Medicaid Program Integrity Unit within Health and Welfare. The unit:
- Identifies billing errors made by providers resulting in unnecessary loss of program dollars; and
- Investigates and prosecutes providers and offenders for filing false or fraudulent claims to the Medicaid program.
- Investigative units work closely with other state and federal investigative agencies and prosecutors to act against offenders and send a message of a zero tolerance for fraud and abuse within the Medicaid program.
What is Health Care Fraud?
Health care fraud is when a provider submits false or fraudulent claims for payment of health care services. Providers may be:
- Hospitals;
- Mental health or case management providers;
- Nursing homes;
- Pharmacies;
- Physicians;
- Dentists;
- Transportation providers; or
- Any other provider who bills the Medicaid program for services.
Common Fraud Schemes
- Altering and/or falsifying records to match services billed;
- Balance billing Medicaid clients for services above the Medicaid payment rate;
- Billing for services not actually performed;
- Billing for services not covered by Medicaid as covered services;
- Billing mid-level services as physician services;
- Billing services for patients who have died;
- Changing the billed dates of service to match client dates of eligibility;
- Deliberately applying for duplicate reimbursement in order to get paid twice;
- Inappropriate billing that results in a loss to the Medicaid program;
- Kickbacks — Providing gifts or incentives for the ability to provide service billed to the Medicaid program;
- Providing service which is not medically necessary;
- Unbundling — Billing related services separately to charge a higher amount than if combined and billed as one service/group of services/panel of services;
- Upcoding — Providing a specific service and billing for a more expensive or detailed service; and
- Violating Medicaid and/or CHIP program policies, procedures, rules, regulations and/or statutes.
Durable Medical Equipment Fraud Schemes
- Billing Medicaid for more expensive equipment than actually supplied;
- Billing used items as new; and
- Continues to send medical supplies when no longer needed.
Hospital/Nursing Home Provider Fraud Schemes
- Billing for more hospital/nursing home days than delivered; and
- False cost reports.
Mental Health Providers
- Billing for services performed by unlicensed or unqualified persons.
Pharmacy Fraud Schemes
- Billing a greater amount of drugs than was actually dispensed;
- Billing for drugs or refills not authorized by a physician; and
- Filling a prescription with a generic drug or over-the-counter drug but billing for a more expensive name-brand drug.
Transportation Fraud Schemes
- Billing for less mileage in an effort to circumvent the need to obtain prior approval;
- Billing for more mileage than incurred; and
- Billing Medicaid for transportation to non-Medicaid services.
Excluded Providers
When a provider or person is found to be involved in fraud or abuse the circumstances may warrant exclusion from participation in the Medicaid program. Once a provider or person is excluded from participation in Idaho Medicaid, they will also be referred to the Office of Inspector General (OIG) for exclusion from any federally funded healthcare program and their name will be published on a national exclusion list.
Providers or persons who have been excluded are prohibited from treating federal program clients or working for providers or entities who treat federal program clients: