Compliance Information

Fraud & Abuse

 

FREQUENTLY ASKED QUESTIONS (FAQs)

What is Medicaid Fraud? 

Fraud is intentional deception or misrepresentation that an individual makes knowing it to be false, and may result in unauthorized benefit payments either to that individual or to some other person. It includes any act that constitutes fraud under any applicable federal or state law.

What are some examples of provider or beneficiary fraud?

• Filing claims for services or items not furnished
• Tampering with prescriptions
• Using stolen Medicaid numbers
• Filing claims for visits never made
• Adding charges that don't exist
• Selling supplies/equipment/medications
• Providing false information
• Medical records
• Claims
• Applications
• Identity of provider or patient

What is Medicaid Abuse? 

Abuse includes incidents or practices that are not consistent within accepted Medicaid or business standards, and may result in unnecessary costs to Medicaid. Abuse may evolve into fraud.

What are some examples of provider or beneficiary abuse?

• Intentionally underreporting income, assets, resources etc.
• Residing out-of-state                                                      
• Drug seeking behaviors                                            
• Over utilization of health care services
• Selling products, medications and/or supplies
• Provider billing irregularities
• Excessive charges for services or supplies
• Claims for services that are not medically necessary
• Improper billing practices by the provider
• Billing for services not provided
• Inaccurate coding
• Misrepresentation of professional credentials/licensing/status of licensure

 

How to Report Fraud, Waste, or Abuse

You can anonymously report suspected fraud, waste and abuse directly to the Director of Quality Assurance and Compliance (802) 952-6059

DVHA link for reporting fraud and abuse:

https://dvha.vermont.gov/providers/program-integrity/program-integrity-contact-information

 

Compliance Resources

• HCRS Ethical Guidelines
• HCRS Corporate Compliance Program
• Definitions of Fraud and Abuse
• HIPAA vs. FERPA
• Causes of Improper Payments