How to Report Medicaid Fraud
Medicaid fraud can be reported to your state Medicaid Fraud Control Unit or through a qui tam case under the federal False Claims Act, which covers the federal share of Medicaid. Many states have their own false claims acts covering the state share, and cases are frequently filed under both.
Medicaid is jointly funded, which changes the case
Medicaid is paid for by both the federal government and the states. The federal False Claims Act reaches the federal share. State false claims acts, where they exist, reach the state share.
A well-structured case is often filed under the federal statute and every applicable state statute at once, which increases the total recovery and therefore the relator award.
Pennsylvania does not have a general false claims act
Pennsylvania is among the states without a general state false claims act, so Pennsylvania Medicaid cases usually proceed under the federal statute alone for the federal share.
Our attorney Ross Wolfe has publicly advocated for Pennsylvania to adopt one. New Jersey, by contrast, has the New Jersey False Claims Act, which does cover the state share.
What Medicaid fraud looks like
The categories overlap with Medicare but skew toward the services Medicaid concentrates in.
- Billing for personal care or home and community based services not provided
- Behavioral health and addiction treatment billed without proper documentation or credentials
- Transportation services billed for trips that did not occur
- Dental and pediatric services billed beyond what was delivered
- Managed care organizations misreporting encounter data or network adequacy
- Kickbacks for patient referrals into treatment programs
Where to report
Every state has a Medicaid Fraud Control Unit, usually inside the state attorney general office, and they investigate provider fraud and patient abuse.
As with Medicare, a hotline report and a qui tam filing are different things. The hotline reports the conduct. The qui tam filing preserves your award rights and your place in line under the first-to-file rule.
Frequently asked questions
Can I report Medicaid fraud anonymously?
State hotlines generally accept anonymous reports, but an anonymous report cannot receive an award. A qui tam case is sealed during the investigation, which protects you while it proceeds.
Do I get paid for reporting Medicaid fraud?
Through a qui tam case, yes. 15 to 30 percent of the federal recovery, plus a share of any state recovery where a state false claims act applies.
What if the fraud spans several states?
That usually increases the value. Multistate cases are filed under the federal statute and each applicable state statute, and states coordinate through the National Association of Medicaid Fraud Control Units.
Does Pennsylvania pay a state award?
Not currently, because Pennsylvania has no general state false claims act. The federal share is still recoverable and the federal award still applies.
The attorneys who handle these cases
Related reading
Talk to a whistleblower attorney before you report
A conversation costs nothing and is confidential. We will tell you honestly whether what you have describes a case, and what the first-to-file rule means for your timing.