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Reporting Fraud, Waste, and Abuse

Carolina Complete Health is serious about finding and reporting times that North Carolina Medicaid is misused. This is called fraud, waste, or abuse.

What is Fraud?

Fraud means to knowingly get benefits or payments that you are not entitled to receive. Please let us know if you are aware of someone who is committing fraud. This could be a provider/doctor or a member. Some examples of health care fraud include:

  • A lie on an application
  • Using someone else's ID card
  • A provider/doctor or other provider billing for services that were not done
  • Transportation usage abuse

What is Waste?

Waste is the overuse of services that may result in costs not needed for health care benefits. This includes direct costs and indirect costs. Waste usually results from the misuse of services.

What is Abuse?

Abuse includes actions that may result in unnecessary costs not needed for health care benefits. This includes direct costs and indirect costs. Abuse can also involve payment for items or services when there is no legal reason to pay for them.

What can you do about health care fraud?

If you think a provider, member, or other personis misusing Medicaid benefits, please tell us right away. We will take your call seriously.

To report potential fraud, waste, or abuse to Carolina Complete Health, please contact us right away. You do not need to give your name.

To report waste, abuse, or fraud, gather as much information as possible.

When reporting about a provider (a doctor, dentist, counselor, etc.) include the following if you can:

  • Name, address, and phone number of provider
  • Name and address of the facility (hospital, nursing home, home health agency, etc.)
  • Type of provider (doctor, dentist, therapist, pharmacist, etc.)
  • Names and phone numbers of other witnesses who can help in the investigation
  • Dates of events
  • Summary of what happened

When reporting about someone who gets benefits, please include:

  • The person’s name
  • The person’s date of birth, Social Security Number, or case number if you have it
  • The city where the person lives
  • Specific details about the waste, abuse, or fraud