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Fraud and Abuse

What is Health Care Fraud and Abuse?

It is when false information is given on purpose. This can be done by a participant or provider. This false information can lead to someone getting a service or benefit that is not allowed. 

Billions of dollars are lost to health care fraud every year. That means money is paid for services that may never have been given. It could also mean that the service that was billed was not the one that was given. 

Here Are Some Other Examples of Fraud and Abuse:

  • Billing for a more expensive service than what was actually given
  • Billing more than once for the same service
  • Billing for services not actually performed
  • Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that are not medically necessary
  • Filing claims for services or medications not received
  • Forging or altering bills or receipts
  • Misrepresenting procedures performed to obtain payment for services that are not covered
  • Over-billing the plan or participant
  • Using someone else's ID and/or Medicaid card
  • Waiving patient co-pays or deductibles

If you know that fraud has occurred, tell us. Call our 24-hour fraud hotline. The toll-free number is 1-866-678-8355. It is private and you may leave a message without leaving your name. If you do leave your phone number, we will call you back. We'll do this to be sure our information is complete and accurate. You can also report fraud on our website. Submitting a report online is private too.

You can also contact the Georgia Department of Community Health's Program Integrity Hotline. Call them at 1-800-533-0686.

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Last Updated On: 4/20/2021