Report Fraud & Abuse
Overview
Surveillance and Utilization Review (SUR) is a program that conducts reviews of medical care, services delivery, and claims payment information to verify the accuracy of the paid claims. These activities help detect and prevent fraud, waste, abuse, and misuse of the Alaska Medical Assistance Program (Medicaid).
All claims submitted to Medicaid are subject to analysis and case review. Identified occurrences of suspected program misuse, suspected fraud, billing irregularities, and over utilization of services are referred to appropriate agencies for further investigation and are subject to potential sanctioning.
Understanding Provider Fraud
Provider fraud is knowingly submitting or authorizing the submission of a medical assistance agency for property, services, or a benefit with reckless disregard that the claimant is not entitled to the property, services, or benefit.
Examples of provider fraud include, but not limited to:
- Billing for services not rendered
- Billing for more costly services than were actually provided (upcoding)
- Billing for services provided by unqualified or unlicensed employees
- Billing for services rendered by an employee no eligible to enroll in Medicaid under an enrolled provider's identification number
- Failure to produce medical assistance records to a person authorized to request the records
Understanding Provider Abuse
Provider abuse is any action inconsistent with generally accepted practices which results in an incorrect payment for services rendered.
Examples of provider abuse include, but not limited to:
- Rendering or ordering excessive services or tests
- Providing services inconsistent with the diagnosis and treatment of the member
- Rendering or ordering medically unnecessary services
- Rendering poor or unsatisfactory quality of care to a member
- Billing a member for remaining balance after Medicaid payment
Understanding Member Fraud and Abuse
Since members do not receive Medicaid payments, member fraud and abuse takes other forms.
The following are examples of, but not limited to, member fraud and abuse:
- Misrepresentation of information to obtain Alaska Temporary Assistance, Food Stamps, Medicaid, and Adult Public Assistance
- Seeking medical treatment to acquire drugs or supplies to support inappropriate use or abuse, for ineligible persons, or to be sold or traded for personal gain
- Visiting medical professionals for essentially social purpose, relief of loneliness, reassurance, or as substitute for more meaningful social activities
- Negligence in caring for durable items (glasses, hearing aids, etc.)
Care Management Program Outreach Brochure
Reporting Fraud, Waste and Abuse
If you suspect a provider or member of engaging in fraud, waste or abuse please notify us through any of these means:
Complaints received are strictly confidential. You may report anonymously, although we prefer to have a way to contact you in case we need more information. If you provide your personal contact information please be assured that it will be kept confidential.
Once received, the complaints are investigated and may be forwarded to one or more of the following agencies:
Division of Health Care Services Quality Assurance Unit
Division of Public Assistance Fraud Control Unit
Division of Senior and Disability Services Quality Assurance Unit
Program Integrity
Medicaid Fraud Control Unit (MFCU)
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