Fraud and Abuse

Welcome to the fraud, waste and abuse web page.

We ask that anyone who suspects fraud, waste or abuse report it. We have included the definitions of fraud, waste and abuse so you will know the type of information to report.

Fraud: Intentionally submitting false information to the government or a government contractor to get money or a benefit. Fraud, in other words, is doing something wrong, and sometimes illegal, to bring money or favors to a healthcare organization.

Waste: Overutilization of services or other practices that directly or indirectly result in unnecessary costs to healthcare programs, such as Medicaid or Medicare.

Abuse: Actions, although unintentional, which may directly or indirectly result in unnecessary costs healthcare programs, such as Medicaid or Medicare. In healthcare, abuse may include things such as poor business practices that may increase the price of services or getting paid for services that are not high quality or that someone really did not need.

Some particular activities that are high risks for Fraud, Waste, and Abuse violations include the following:

• Submitting a false claim that a provider uses to receive payment for a service;
• Submitting a claim for a service that did not occur;
• Using the wrong billing code in order to be paid more;
• Billing for a longer period of time than was actually spent delivering the service;
• Billing for a service that really was not needed;
• Taking or giving bribes, which could be money or gifts, so the provider will get more business or other favors;
• Paying someone so they will give you more business or individuals to serve;
• Submitting a claim with inadequate or poor documentation to support the service that was billed; or
• Making up a record to pretend that a service or treatment was provided, even though it was not.

Report Potential Fraud

• Carelon Behavioral Health:
  Report By Mail:
  Carelon Behavioral Health
  Attn: Compliance Officer
  229 Peachtree Street, NE
  18th floor
  Atlanta, GA 30303

   

  Report By Phone:
  888-293-3027

  Additional numbers TBD

  Report By E-mail:
  TBD

• Georgia Office of Inspector General:
  Report By Mail:
  Office of Inspector General
  ATTN: Special Investigations Unit
  2 Peachtree Street, NW 5th Floor
  Atlanta, GA 30303

   

  Report By Phone:
  404-463-7590
  800-533-0686

  Report By E-mail:
  oiganonymous@dch.ga.gov or
  ReportMedicaidFraud@dch.ga.gov
  or
  Report fraud using online form.

Compliance Policies and Procedures

• Georgia Compliance and Program Integrity Plan (Under Review)
• Carelon Behavioral Health Program Integrity Plan (Under Review)
• Carelon Behavioral Health FWA Investigation Policy (Under Review)

Laws and Regulations

• Balanced Budget Act
• Deficit Reduction Act
• Federal False Claims Act (2008 corrections)
• Federal False Claims Act Primer
• Federal Regulation 42 Title VI (included Medicaid Managed Care 438)
• Fraud Enforcement and Recovery Act (FERA)
• Patient Protection and Affordable Care Act (PPACA)
• Practical Guidance for Health Care Governing Boards on Compliance Oversight
• Health Information Portability and Accountability Act (HIPAA)
• Health Information Technology for Economic and Clinical Health Act (HITECH)
• Federal Substance Use Disorder Privacy Law
• Georgia OIG False Claims Act Approval Letter

Program Integrity Links

• CMS Fraud, Waste and Abuse Training and Compliance Training
• Audits – Medicaid RAC
• Code of Federal Regulation (Title 42 – Public Health, Chapter IV – CMS, DHHS, Subchapter C-Medical Assistance Programs, Part 455 – Program Integrity Medicaid
• Office of Inspector General (OIG)
• Center for Medicare and Medicaid Services (CMS)
• National Association of Medicaid Fraud Control Units (NAMFCU)
• Georgia Medicaid Fraud Control Unit
• Georgia Medicaid Program Integrity

In the News

• Marietta man sentenced to seven years in prison for Medicaid fraud
• Clayton county woman sentenced to ten years in prison for Medicaid fraud
• Former GA Medicaid provider charged for fraudulent billing
• GA pair accused of income tax evasion
• Former GA Medicaid provider indicted on fraud charges
• Four GA co-defendants accused of falsely billing Medicaid
• Youth counselors charged for defrauding GA Medicaid
• Two plead guilty for role in elaborate GA Medicaid fraud scheme
• Judge sentences two defendants to prison for defrauding GA Medicaid
• Owner and employees of Metro Atlanta MH company indicted
• Clayton county MH provider of children’s service indicted
• Fraud-Wary Feds to Regulate EHR Copy-and-Paste Function