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​Reporting Suspected MA Fraud & Abuse

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. 

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. 

Report Suspected Fraud or Abuse with the MA Provider Compliance Response FormOpens In A New Window

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:

        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. 

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 §1101.75. Recipient prohibited acts are listed at §1101.92.