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Medical Services - Fraud & Abuse

The North Dakota Department of Human Services' mission is to provide quality, efficient, and effective human services, which improve the lives of people.

Medicaid and the Children's Health Insurance Program (CHIP) provides healthcare coverage to qualifying low-income, disabled individuals and children, and families. Fraud can be committed by Medicaid providers or recipients. The Department does not tolerate misspent or wasted resources.

By enforcing fraud and abuse efforts:

  • Medicaid providers receive the best possible rates for the services they provide to Medicaid & CHIP recipients;
  • Medicaid & CHIP recipients are assured that their out-of-pocket costs are as low as possible;
  • Tax dollars are properly spent;
  • North Dakota Medicaid & CHIP recipients receive necessary healthcare services.

ND Medicaid Provider Exclusion List (April 2014)
Qualified Service Provider (QSP) Exclusion List (July 2014)


What is Fraud? Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to them or some other person.

What is Abuse?Abuse is when provider practices are inconsistent with sound fiscal, business, or medical practices that result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or services that fail to meet professional recognized standards for healthcare. Abuse may also include recipient practices that result in unnecessary costs to the Medicaid and CHIP programs.


What are the types of fraud or abuse?

Provider: committed by practitioner, health facility, or other entity that provides services to Medicaid recipients.

Examples:

  • Billing for services not performed
  • Billing for a more expensive service than was actually rendered
  • Billing twice for the same service(s)
  • Billing for services that should be combined into one billing (unbundling)

Recipient: committed by a Medicaid or CHIP recipient

Examples:

  • Providing false information to obtain Medicaid or CHIP eligibility
  • Paying cash for some services (prescriptions) to bypass refill edits
  • A recipient may lend someone their Medicaid card so the individual can obtain unauthorized medical services.

Who can report fraud or abuse to North Dakota Medicaid/CHIP?

  • Healthcare providers
  • Medicaid or CHIP recipients
  • County or State staff
  • Any concerned individual

What is my role in helping prevent Medicaid/CHIP fraud and abuse?

REPORT any instance of suspected fraud or abuse.

What is my role as a Medicaid recipient in preventing fraud and abuse?

  • As a Medicaid recipient, if a provider suggests treatment or services that you do not believe are necessary, be cautious of the recommendation.
  • Recipients should be wary of "free" tests, services, or medical products offered in exchange for your Medicaid information.
  • Randomly, ND Medicaid will send out a Recipient Explanation of Medicaid Benefits (REOMB) in order to ensure recipients are accurately receiving the services that providers are billing for. These should be reviewed, and any inaccurate billings should be reported to ND Medicaid.

How do I report Medicaid fraud or abuse?

How do I report CHIP or Healthy Steps concerns?

  • Call Blue Cross Blue Shield of ND at 1.800.342.4718

What does North Dakota Medicaid or CHIP do after a referral of fraud or abuse is received?

  • Provide education to providers or recipients
  • Conduct a provider or recipient investigation
  • Conduct a provider audit or onsite review
  • Refer, if appropriate, to an agency for further investigation or prosecution

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