Medicaid Fraud and Abuse | Department of Human Services | Commonwealth of Pennsylvania
Source: https://www.pa.gov/agencies/dhs/report-fraud/medicaid-fraud-abuse
Archived: 2026-04-23 17:15
Medicaid Fraud and Abuse | Department of Human Services | Commonwealth of Pennsylvania
Report Suspected Medicaid Fraud and Abuse
The Department of Human Services (DHS) is committed to eliminating all forms of fraud and abuse within the Medicaid program. Your help will enable us to accomplish this goal.
Overview
The vast majority of Medicaid providers and recipients provide and receive care within the boundaries of applicable regulations.
Unfortunately, a small number of Medicaid recipients and providers engage in practices that are fraudulent or abuse of the Medicaid program. Dollars lost to such practices are then unavailable for providing care to those in need.
Examples of fraud and abuse
Falsifying Claims/Encounters
Billing for services not rendered
Billing separately for services in lieu of an available combination code
Misrepresentation of the service/supplies rendered (billing brand name for a generic drug, upcoding to more expensive service than was rendered, billing for more time or units of service than provided)
Altering claims
Submission of any false data on claims, such as date of service, provider or prescriber of service
Duplicate billing for the same service
Billing for services provided by unlicensed or unqualified persons
Billing for used items as new
Administrative/Financial
Falsifying credentials
Fraudulent enrollment practices
Fraudulent third-party liability reporting
Offering free services in exchange for a recipient's Medical Assistance identification number
Providing unnecessary services/overutilization
Kickbacks-accepting or making payments for referrals
Concealing ownership of related companies
Recipient Fraud and Abuse
Forging or altering prescriptions or orders
Using multiple ID cards
Loaning his/her ID card
Reselling items received through the Medical Assistance program
Intentionally receiving excessive drugs, services or supplies
Abuse of Recipients
Physical, mental, emotional or sexual abuse
Discrimination
Neglect
Providing substandard or inappropriate care
Denial of Services
Denying access to services
Limiting access to services
Failure to refer to a needed specialist
Underutilization
Review of Medical Assistance General Regulations
View the
Pennsylvania Code
. Provider prohibited acts are listed at 55 Pa. Code §1101.75. Recipient prohibited acts are listed at 55 Pa. Code §1101.92.
Department of Human Services
Office of Administration
Bureau of Program Integrity
P.O. Box 2675
Harrisburg, PA 17105-2675
Reported problems will be referred to the appropriate Office of Administration's Bureau of Program Integrity for investigation, analysis, and determination of the appropriate course of action.
Report Suspected Fraud or Abuse with the MA Provider Compliance Response Form
Suspected fraud and abuse can also be reported by telephone at 1-844-DHS-TIPS (1-844-347-8477) or by writing to us at:
Report Suspected Medicaid Fraud and Abuse
The Department of Human Services (DHS) is committed to eliminating all forms of fraud and abuse within the Medicaid program. Your help will enable us to accomplish this goal.
Overview
The vast majority of Medicaid providers and recipients provide and receive care within the boundaries of applicable regulations.
Unfortunately, a small number of Medicaid recipients and providers engage in practices that are fraudulent or abuse of the Medicaid program. Dollars lost to such practices are then unavailable for providing care to those in need.
Examples of fraud and abuse
Falsifying Claims/Encounters
Billing for services not rendered
Billing separately for services in lieu of an available combination code
Misrepresentation of the service/supplies rendered (billing brand name for a generic drug, upcoding to more expensive service than was rendered, billing for more time or units of service than provided)
Altering claims
Submission of any false data on claims, such as date of service, provider or prescriber of service
Duplicate billing for the same service
Billing for services provided by unlicensed or unqualified persons
Billing for used items as new
Administrative/Financial
Falsifying credentials
Fraudulent enrollment practices
Fraudulent third-party liability reporting
Offering free services in exchange for a recipient's Medical Assistance identification number
Providing unnecessary services/overutilization
Kickbacks-accepting or making payments for referrals
Concealing ownership of related companies
Recipient Fraud and Abuse
Forging or altering prescriptions or orders
Using multiple ID cards
Loaning his/her ID card
Reselling items received through the Medical Assistance program
Intentionally receiving excessive drugs, services or supplies
Abuse of Recipients
Physical, mental, emotional or sexual abuse
Discrimination
Neglect
Providing substandard or inappropriate care
Denial of Services
Denying access to services
Limiting access to services
Failure to refer to a needed specialist
Underutilization
Review of Medical Assistance General Regulations
View the
Pennsylvania Code
. Provider prohibited acts are listed at 55 Pa. Code §1101.75. Recipient prohibited acts are listed at 55 Pa. Code §1101.92.
Department of Human Services
Office of Administration
Bureau of Program Integrity
P.O. Box 2675
Harrisburg, PA 17105-2675
Reported problems will be referred to the appropriate Office of Administration's Bureau of Program Integrity for investigation, analysis, and determination of the appropriate course of action.
Report Suspected Fraud or Abuse with the MA Provider Compliance Response Form
Suspected fraud and abuse can also be reported by telephone at 1-844-DHS-TIPS (1-844-347-8477) or by writing to us at: