MA Fraud and Abuse - General Information

The vast majority of Medical Assistance (MA) providers and recipients provide and receive care within the boundaries of applicable regulations. Unfortunately, a small number of Medical Assistance recipients and providers engage in practices that are fraudulent or abuse of the Medical Assistance program. Dollars lost to such practices are then unavailable for providing care to those in need. The Department of Human Services is committed to eliminating all forms of fraud and abuse within the Medical Assistance program. Your help will enable us accomplish this goal. You can report suspected fraud and abuse by telephone (1-866-DHS-TIPS ), U. S. Mail, or email.

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 appropriate for reporting are set forth below:

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 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 needed specialist
  • Underutilization

Review Medical Assistance General Regulations:
View the Pennsylvania Code. Provider prohibited acts are listed at §1101.75. Recipient prohibited acts are listed at §1101.92.