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.
• Kickbacks.

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:

• Cooperate.
• 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.

HELPFUL LINKS:

• Office of the Inspector General Compliance Resources
• Center for Medicare and Medicaid Services (CMS) Fraud, Waste and Abuse Toolkit