Program Integrity: Report Fraud, Waste and Abuse
Sandhills Center's Program Integrity department looks into reports of fraud, waste and abuse of the Medicaid program and State-Funded services system.
EXAMPLES OF FRAUD
- Billing services that were not provided.
- Falsifying credentialing applications.
- Falsifying client records.
EXAMPLES OF WASTE AND ABUSE
- Providing services that are not medically necessary.
- Failure to follow the requirements of the service definition.
- Using treatments that are not evidence-based.
- Using a higher-cost treatment when a lower-cost treatment could be equally effective.
PROVIDERS' RESPONSIBILITIES DURING AN INVESTIGATION OR POST-PAYMENT REVIEW:
- Provide requested records.
- Communicate with Sandhills Center's Program Integrity staff, as necessary.
PROGRAM INTEGRITY DEPARTMENT'S RESPONSIBILITIES DURING AN INVESTIGATION OR POST-PAYMENT REVIEW:
- Minimize disruption to client services.
- Approach each investigation or review without bias.
- Communicate with providers as allowed by policy, rule and law.
TO REPORT FRAUD, WASTE OR ABUSE:
- Call Member & Recipient Services: 1-800-256-2452 (TTY: 1-866-518-6778)
- Call the Sandhills Center Program Integrity department directly: 336-389-6136.
- Use the Fraud Referral Form [link coming soon]
- Contact the Attorney General's Medicaid Investigation Division: 919-881-2320.
- Office of the Inspector General Compliance Resources
- Center for Medicare and Medicaid Services (CMS) Fraud, Waste and Abuse Toolkit