Medical Services Fraud and Abuse

Medium

Medicaid and the Children's Health Insurance Program (CHIP) provide health care coverage to qualifying low-income, disabled individuals and children, and families. Fraud can be committed by Medicaid providers or members. The department does not tolerate misspent or wasted resources.

By enforcing fraud and abuse efforts:

  • Medicaid providers receive the best possible rates for the services they provide to Medicaid & CHIP members;
  • Medicaid & CHIP members are assured that their out-of-pocket costs are as low as possible;
  • Tax dollars are properly spent;
  • North Dakota Medicaid & CHIP members receive necessary health care services.

If a provider on the ND Medicaid Provider Exclusion list is a Qualified Services Provider (QSP), they will not have a National Provider ID number. North Dakota can verify QSP providers by name, date of birth, and last four of their social security number.

ND Medicaid Provider Exclusion List- Includes Qualified Service Providers (December 2024) PDF
ND Medicaid Provider Exclusion List - Includes Qualified Service Providers (December 2024) Excel

Searchable National Provider ID Registry

Reporting Suspected Medicaid Fraud

To report suspected Medicaid Fraud, email medicaidfraud@nd.gov or call (800) 755-2604 - select option 3. You may also complete the Suspected Fraud Referral (SFN 20) form and submit it to the department.

Email all inquiries to medicaidfraud@nd.gov.

Fraud and Abuse Questions

Medium

Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to them or some other person.

Abuse is when provider practices are inconsistent with sound fiscal, business, or medical practices that result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or services that fail to meet professionally recognized standards for healthcare. Abuse may also include recipient practices that result in unnecessary costs to the Medicaid and CHIP programs.

Provider: committed by the practitioner, health facility, or other entity that provides services to Medicaid recipients.

Examples:

  • Billing for services not performed
  • Billing for a more expensive service than was actually rendered
  • Billing twice for the same service(s)
  • Billing for services that should be combined into one billing (unbundling)

Recipient: committed by a Medicaid or CHIP recipient

Examples:

  • Providing false information to obtain Medicaid or CHIP eligibility
  • Paying cash for some services (prescriptions) to bypass refill edits
  • A recipient may lend someone their Medicaid card so the individual can obtain unauthorized medical services.

  • Healthcare providers
  • Medicaid or CHIP recipients
  • County or State staff
  • Any concerned individual

REPORT any instance of suspected fraud or abuse.

What is my role as a Medicaid recipient in preventing fraud and abuse?

  • As a Medicaid recipient, if a provider suggests treatment or services that you do not believe are necessary, be cautious of the recommendation.
  • Recipients should be wary of "free" tests, services, or medical products offered in exchange for your Medicaid information.
  • Randomly, ND Medicaid will send out a Recipient Explanation of Medicaid Benefits (REOMB) in order to ensure recipients are accurately receiving the services that providers are billing for. These should be reviewed, and any inaccurate billings should be reported to ND Medicaid.

Complete the Suspected Fraud Referral (SFN 20) form

Call:

Phone: (701) 328-4024
Toll-Free: 1 (800) 755-2604

Email:

Email: medicaidfraud@nd.gov

Mail:

Fraud, Waste and Abuse Administrator
c/o Medical Services Division
600 E Boulevard Ave Dept 325
Bismarck ND 58505-0250

Fax

Fax: (701) 328-1544

  • Provide education to providers or recipients.
  • Conduct a provider or recipient investigation.
  • Conduct a provider audit or onsite review.
  • Refer, if appropriate, to an agency for further investigation or prosecution.
Medium