What Medicaid Fraud Looks Like and How to Report It

How to recognize signs of Medicaid fraud and where to report it

Medicaid is a health insurance program that serves millions of low-income families, seniors, and people with disabilities. In North Carolina alone, more than two million residents rely on Medicaid for doctor visits, prescriptions, and hospital care. The program is funded with both state and federal dollars, so fraud harms everyone who pays taxes and everyone who depends on Medicaid services. When fraudulent activity occurs, resources are drained, wait times increase, and trust in the system suffers. Consumers who understand what fraud looks like are better prepared to stop it by reporting suspicious activity.

Examples of Medicaid fraud

Fraud can take many forms. Some cases involve health care providers who overbill or charge for services that never occurred. Others involve patients misusing their benefits or people outside the system trying to profit from stolen information. Here are common examples:

• Billing for services not provided. Submitting claims for visits, procedures, or equipment that patients never received.
• Using another person’s Medicaid card. Borrowing or stealing someone else’s insurance information to obtain medical services or prescriptions.
• Kickbacks for patient referrals. Accepting or offering money, gifts, or favors in exchange for sending patients to particular clinics or pharmacies.
• Inflated or duplicate billing. Charging more than the actual cost of services or submitting the same claim multiple times.
• Unnecessary services. Ordering tests, treatments, or equipment that are not medically needed, solely to increase billing.
• Prescription fraud. Forging prescriptions, overprescribing controlled substances, or diverting medications for resale.

These schemes may appear minor, but added together they drain billions from Medicaid nationwide. Even a single false claim shifts resources away from patients who truly need care.

Warning signs for patients

Patients and caregivers are often the first line of defense against fraud. Pay close attention to bills, explanation-of-benefits statements, and provider requests. Red flags include:

• Blank forms. Being asked to sign insurance claim forms that are not filled out completely.
• Phantom charges. Receiving bills for services, equipment, or prescriptions that you never received.
• High-pressure tactics. Feeling pressured to accept medical tests, devices, or treatments that do not seem necessary.
• Unfamiliar providers. Seeing charges from doctors or clinics you never visited.
• Prescription discrepancies. Pharmacies filling larger amounts of medication than prescribed or refilling prescriptions too early.

Keeping your own medical records can help you spot these issues. Write down the dates you visited doctors, the services you received, and the prescriptions you filled. Compare your notes to the statements you receive from Medicaid. If they do not match, it may be a sign of fraud.

Consequences of fraud

Fraud is not a victimless crime. Every dollar lost to fraud is a dollar that cannot be used for children’s checkups, senior care, or lifesaving treatments. Fraud can lead to higher costs for taxpayers and tighter restrictions on services. In some cases, it can even put patients in danger by exposing them to unnecessary procedures or unsafe prescriptions. Providers caught committing fraud may face fines, loss of licenses, or even prison sentences. Patients who knowingly share cards or participate in fraud can also face penalties.

How to report Medicaid fraud

If you suspect fraud, you do not need proof before reporting. Investigators will determine whether fraud has occurred. What matters is alerting the right offices so they can review the case. Reporting can be done anonymously in many instances.

• State Medicaid Fraud Investigations Division. In North Carolina, this division investigates both providers and recipients when fraud is suspected.
• Attorney General’s office. The state Attorney General accepts complaints related to Medicaid fraud and consumer protection violations.
• U.S. Department of Health and Human Services hotline. A federal hotline is available for reporting Medicaid and Medicare fraud nationwide.
• Local health departments. Some county health offices can guide residents on where to report issues.

When reporting, include as much detail as possible: names of providers, dates of service, descriptions of suspicious behavior, and copies of bills or statements. Do not delay reporting because you lack some details. Even partial information can help investigators uncover larger patterns.

Protecting yourself from fraud

Consumers can also take steps to avoid becoming victims of fraud or misuse. Protect your Medicaid card and personal information as carefully as you would protect a credit card. Here are some precautions:

• Never share your card. Do not allow friends or family to use your Medicaid card, even for emergencies.
• Guard your information. Keep your Medicaid number private and be cautious about giving it out over the phone or online.
• Review your records. Check your Medicaid statements regularly to confirm that charges match the care you actually received.
• Shred old documents. Dispose of outdated medical or insurance papers securely to prevent identity theft.
• Ask questions. If a provider recommends a treatment or service you don’t understand, ask for a clear explanation.

Quick Checklist

• Know the common types of Medicaid fraud.
• Watch for unusual charges or blank forms.
• Keep your own records of visits and prescriptions.
• Report suspicious activity promptly.
• Protect your Medicaid card and personal information.

Medicaid fraud harms everyone, from taxpayers to patients who rely on care. By learning the warning signs, keeping good records, and reporting concerns, you help protect the program and ensure that funds remain available for those who need them most. Vigilance makes a real difference. Even small steps by individual consumers can help close the door on fraud and keep health care resources focused where they belong: on patient care.