Fraud and Abuse

Health care fraud is a significant problem faced by all state, federal and private health plans. The Department for Medicaid Services (DMS) works with the Office of the Inspector General (OIG) to combat fraud and abuse.

DMS actively refers suspicious or questionable activity identified by staff or reported by outside sources to OIG for thorough and prompt review. Investigators skilled in detection and investigation of fraud and abuse review all referrals and evaluate the need for further action.

What is Fraud and Abuse?

Recovery Branch

The Recovery Branch in the Division of Program Integrity is responsible for several key tasks related to Medicaid, including helping the department identify and respond to fraud, waste, and abuse. The branch serves as the liaison for the Unified Program Integrity Contractor and works closely with the Audits and Compliance Branch in establishing the necessary accounts regarding Medicaid-conducted audits.

Fraud referrals for providers and/or members can be received via hotline calls, others agency referrals, programming discrepancies, or identified from quarterly reviews, explanation of Medical Benefits documents, newspapers, television reports, federal alerts, etc. Once a referral is received, the branch initiates a review and begins the process to collect on outstanding accounts. Before there is any change to a provider's participation in the Medicaid program, the Recovery Branch team conducts a review of the provider's application, maintenance, and revalidation for provider enrollment. In addition to outstanding accounts, staff within the branch also oversee and monitor Denial of Payment for New Admissions for Nursing Facilities received from the federal Centers for Medicare and Medicaid Services; and providers, entities, or Participant Directed Services (PDS) employees and/or members who are the subjects of a fraud investigation.

The branch also receives and researches bankruptcy notices to protect the department's interests; provides Date of Death account monitoring on providers and members if claim have been paid after the date of death; and communicate regularly with many areas, including sister agencies, contractors, and federal partners. Additionally, the branch is tasked with researching the receipt of bills received by members when they are eligible for Medicaid, and reviews the small package of Medicaid members who engage in fraudulent behavior.

Report Fraud

To report fraud or abuse, contact:

Cabinet for Health and Family Services
Office of the Inspector General
Division of Audits and Investigations
275 E. Main St. 5E-D
Frankfort, KY 40621
Toll Free: (800) 372-2970
Monday through Friday, 8 a.m. - 4:30 p.m.