Fraud, Waste and Abuse
The Department is actively working to combat fraud, waste and abuse.
Fraud includes making a false statement or misrepresenting information to get something that benefits oneself or someone else. There are many forms of fraud.
Waste includes over-utilizing Health First Colorado (Colorado's Medicaid Program) services, supplies or equipment, or causing unnecessary costs through carelessness or inefficiency.
Abuse* includes activities that result in unnecessary costs to Health First Colorado.
*Please note: Report physical or emotional abuse to the police.
Health First Colorado Provider Fraud
Examples of actions by Health First Colorado providers which may be fraud include:
- Billing Health First Colorado for doctor visits, medical procedures, drugs or supplies that are not provided to a client
- Billing for the same service twice
Health First Colorado Member Fraud
Examples of actions by Health First Colorado (Colorado's Medicaid Program) members which may be fraud include:
Eligibility Determination Fraud
- Unreported Income
- Household Composition
- Resource Misrepresentation (Transfer/Hiding)
- Residency (lives outside the state of Colorado)
- Citizenship Status
Other Types of Fraud
- Using another person’s Health First Colorado card
- Selling or buying a Health First Colorado card
- Forging prescriptions
- Concealing access to other health insurance
- Misrepresenting a medical condition
- Going to different medical providers, with the intent to deceive, in search of a controlled substance
- Diverting prescriptions to others
- Selling supplies provided by Health First Colorado to others
How You Can Help
If you suspect Health First Colorado fraud, waste or abuse, please report it to us immediately.
- Our Benefits Coordination Section recovers money and avoids unnecessary costs
- Our Client Over-utilization Program works to detect and reduce over-utilization of Health First Colorado services, supplies or equipment
- Our Nursing Facility Section works to detect and reduce fraud, waste and abuse
- Our Program Integrity Section works to detect and recover inappropriate payments to Health First Colorado providers and to review possible fraud by Health First Colorado providers
- Our Audit Information Management Section works to reduce fraud, waste, and abuse committed by recipients of our programs and to recover inappropriate payments to Health First Colorado providers through data mining review