Overview
The vast majority of Medicaid providers and recipients provide and receive care within the boundaries of applicable regulations.
Unfortunately, a small number of Medicaid recipients and providers engage in practices that are fraudulent or abuse of the Medicaid program. Dollars lost to such practices are then unavailable for providing care to those in need.
Examples of fraud and abuse
Falsifying Claims/Encounters
- Billing for services not rendered
- Billing separately for services in lieu of an available combination code
- Misrepresentation of the service/supplies rendered (billing brand name for a generic drug, upcoding to more expensive service than was rendered, billing for more time or units of service than provided)
- Altering claims
- Submission of any false data on claims, such as date of service, provider or prescriber of service
- Duplicate billing for the same service
- Billing for services provided by unlicensed or unqualified persons
- Billing for used items as new
Administrative/Financial
- Falsifying credentials
- Fraudulent enrollment practices
- Fraudulent third-party liability reporting
- Offering free services in exchange for a recipient's Medical Assistance identification number
- Providing unnecessary services/overutilization
- Kickbacks-accepting or making payments for referrals
- Concealing ownership of related companies
Recipient Fraud and Abuse
- Forging or altering prescriptions or orders
- Using multiple ID cards
- Loaning his/her ID card
- Reselling items received through the Medical Assistance program
- Intentionally receiving excessive drugs, services or supplies
Abuse of Recipients
- Physical, mental, emotional or sexual abuse
- Discrimination
- Neglect
- Providing substandard or inappropriate care
Denial of Services
- Denying access to services
- Limiting access to services
- Failure to refer to a needed specialist
- Underutilization
Review of Medical Assistance General Regulations
View the Pennsylvania Code. Provider prohibited acts are listed at 55 Pa. Code §1101.75. Recipient prohibited acts are listed at 55 Pa. Code §1101.92.
Department of Human Services
Office of Administration
Bureau of Program Integrity
P.O. Box 2675
Harrisburg, PA 17105-2675
Reported problems will be referred to the appropriate Office of Administration's Bureau of Program Integrity for investigation, analysis, and determination of the appropriate course of action.
Report Suspected Fraud or Abuse with the MA Provider Compliance Response Form
Suspected fraud and abuse can also be reported by telephone at 1-844-DHS-TIPS (1-844-347-8477) or by writing to us at: