Reporting Fraud, Waste, and Abuse

Identify health care fraud and abuse, learn how it impacts the state health care system, and find out how to make a confidential report.

Health care fraud and abuse impacts everyone and costs North Carolina millions of dollars every year. That is why Partners has a group of professional investigators and auditors in our Program Integrity Department who work with our compliance unit to eliminate health care fraud and abuse.

  • Fraud occurs when a person knowingly does something wrong that benefits them or another person.
  • Abuse (and Waste) occurs when the use of health care services or funds result in unnecessary cost. Waste and abuse are not necessarily intentional.

The full legal definition of fraud and abuse can be found in the Code of Federal Regulations (CFR) 42 Part 455.2.

Consider these examples of health care fraud and abuse:

  • A provider bills for services, tests, or equipment you did not receive
  • A provider bills for services they are not licensed to perform
  • Someone uses your identity for their benefit, with or without your consent
  • A provider bills for a higher level of service than what was provided

How to Report Fraud or Abuse

Help us fight health care fraud and abuse. If you suspect billing for a service, a conflict of interest, a violation of Medicaid or Medicare rules, or conduct violation might be illegal, please report your concerns to:

You do not have to provide your name or contact information. However, we can often conduct a more effective investigation if you let us contact you. Your name will not be shared with anyone investigated.

Note: In rare cases involving legal proceedings, your identity may have to be revealed.

Tips to Prevent Health Care Fraud and Abuse

  • Be suspicious of anyone who claims they know a way to get services paid for that may otherwise not be paid.
  • Know what services you are receiving and what is being billed on your behalf.
  • Protect your Medicaid Number and do not let anyone borrow your Medicaid Card.
  • Do not sign your name to a blank form.
  • Be suspicious if someone offers you free services or gifts in exchange for your Medicaid information.
  • Always report any concerns of possible fraud or abuse. You do not have to be certain that wrongdoing has occurred to report it.

If you suspect other forms of healthcare or Medicaid fraud or abuse, contact:

  • Division of Medical Assistance at 1-800-662-7030 (English and Spanish)
  • Medicaid Fraud, Waste and Program Abuse Tip Line at 1-877-DMA-TIP1 (1-877-362-8471)

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