Sandhills Center’s Program Integrity (PI) department investigates complaints of fraud, waste and abuse of the Medicaid program and IPRS system.
Examples of Fraud:
- Billing services not provided
- Falsifying credentialing application
- Falsifying client records
Examples of Waste and Abuse:
- Providing services not medically necessary.
- Failure to adhere to the requirements of the service definition.
- Using treatments that are not evidence-based.
- Using a higher cost treatment when a lower cost treatment could be equally effective.
Providers’ responsibilities during an investigation or post-payment review:
- Provide requested records
- Communicate with program integrity staff as necessary
The Program Integrity department’s responsibilities during an investigation or post-payment review:
- Minimize disruption to client services.
- Approach each investigation or review without bias.
- Communicate with providers as allowed by policy, rule and law.
To report Fraud, Waste or Abuse:
- Call Sandhills Center 24 hours a day, seven days a week — 1-800-256-2452.
- Call the Sandhills Center Program Integrity department directly — (336) 389-6236.
- Use DMA’s confidential online complaint form.
- Contact the Attorney General’s Medicaid Investigation Division — (919) 881-2320.
- Office of the Inspector General “Compliance 101″
- Center for Medicare and Medicaid Services (CMS) Fraud, Waste and Abuse Toolkit