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Reporting Fraud, Waste, and Abuse

Carolina Complete Health is serious about finding and reporting times that North Carolina Medicaid is misused. This is called fraud, waste, or abuse.

Billions of dollars are lost to health care fraud every year. That means money is paid for services that may never have been given. It could also mean that the service that was billed was not the one that was performed.

What is Fraud?

Fraud means to knowingly get benefits or payments that you are not entitled to receive. Please let us know if you are aware of someone who is committing fraud. This could be a provider/doctor or a member. Some examples of health care fraud include:

  • A lie on an application, such as not reporting all income or other health insurance
  • Using someone else's ID card
  • A provider/doctor or other provider billing for services that were not done or were not medically necessary
  • Transportation usage abuse

What is Waste?

Waste is the overuse of services that may result in costs not needed for health care benefits. This includes direct costs and indirect costs. Waste usually results from the misuse of services.

What is Abuse?

Abuse includes actions that may result in unnecessary costs not needed for health care benefits. This includes direct costs and indirect costs. Abuse can also involve payment for items or services when there is no legal reason to pay for them.

What can you do about health care fraud?

If you think a provider, member, or other personis misusing Medicaid benefits, please gather as much information as possible.

When reporting about a provider (a doctor, dentist, counselor, etc.) include the following if you can:

  • Name, address, and phone number of provider
  • Name and address of the facility (hospital, nursing home, home health agency, etc.)
  • Type of provider (doctor, dentist, therapist, pharmacist, etc.)
  • Names and phone numbers of other witnesses who can help in the investigation
  • Dates of events
  • Summary of what happened

When reporting about someone who gets benefits, please include:

  • The person’s name
  • The person’s date of birth, Social Security Number, or case number if you have it
  • The city where the person lives
  • Specific details about the waste, abuse, or fraud

How To Report Fraud and Abuse

If you think fraud has taken place, call our 24-hour hotline. The number is 1-866-685-8664 (TTY: 711). It is private and you may leave a message without leaving your name. If you do leave your phone number, we will call you back to be sure our information is complete and accurate. You can also submit your concern online.

You can report suspected fraud and abuse in any of the following ways:

  • Call the Medicaid Fraud, Waste and Program Abuse Tip Line at 1-877-DMA-TIP1 (1-877-362-8471)
  • Call the State's Auditor's Waste Line at 1-800-730-TIPS (1-800-730-8477)
  • Call the U.S. Office of Inspector General's Fraud Line at 1-800-HHS-TIPS (1-800-447-8477)
  • Submit the report online
  • Call the North Carolina Attorney General's Medicaid Investigation Division Hotline at 1-919-881-2320