Medicaid Fraud Control Unit
The Medicaid Fraud Control Unit investigates and prosecutes fraud by healthcare providers who treat Medicaid beneficiaries.
Healthcare providers include, but are not limited to, hospitals, nursing homes, doctors, dentists, pharmacies, ambulance companies, and anyone else who is paid for providing healthcare services to Medicaid beneficiaries. The Medicaid Program has more than 22,000 enrolled providers serving 130,000 beneficiaries.
The Unit also investigates and prosecutes cases of harm to residents of healthcare facilities that is caused by abuse, neglect or financial exploitation. There are 86 licensed facilities in New Hampshire serving more than 7,000 residents.
If you would like to report a case involving suspected fraud by a recipient of Medicaid services, please contact the Program Integrity Unit of the New Hampshire Department of Health and Human Services at (603) 271-8029.
The Medicaid Fraud Control Unit receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $987,576 for Federal fiscal year (FY) 2024. The remaining 25 percent, totaling $329,191 for FY 2024, is funded by the State of New Hampshire.
What is Medicaid Fraud?
Examples of Medicaid Fraud:
- Billing for services not rendered: A provider bills Medicaid for a procedure or service that was not actually provided.
- Billing for upcoded services: A provider misrepresents the diagnosis and symptoms on patient records or selects higher paying procedure codes to obtain greater reimbursement than allowed.
- Billing for uncovered services: A provider bills Medicaid for a service that requires the use of licensed or certified personnel but uses unqualified staff.
- Drug substitution: A pharmacist fills a recipient's prescription with a generic drug, but bills Medicaid for a higher cost brand name drug.
- Kickbacks: A provider offers or pays a kickback to induce someone to refer Medicaid recipients to that provider as patients or clients. Examples of kickbacks include cash, vacations, and gifts.
- Supplemental Charges: A provider charges a Medicaid recipient for a service which is covered by Medicaid and should be billed to Medicaid, and then charges the recipient the difference between the provider's usual fee and what Medicaid pays.
- Inflating the Usual and Customary Charges: A provider charges Medicaid more than their usual and customary charge for the same product or service billed to other insurers and the public. A provider might inflate the cost of the procedure, service or goods provided.
What is Resident Abuse, Neglect and Financial Exploitation?
Resident abuse or neglect is any action or failure to act that causes unjustifiable harm to a healthcare facility resident. It includes physically assaulting a resident as well as withholding necessary food, care, or medical treatment. The Unit investigates reports of abuse and neglect in any in-patient or residential healthcare setting, including hospitals, nursing homes, and assisted living facilities.
Resident financial exploitation is the illegal or improper use of the funds or assets of a healthcare facility resident. It includes the misuse of personal funds held at the facility and may also include the misuse of funds by a resident's designated financial agent.