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 Medicaid services, supplies or equipment, or causing unnecessary costs through carelessness or inefficiency.

Abuse* includes activities that result in unnecessary costs to Medicaid.

*Please note: Report physical or emotional abuse to the police.

Medicaid Provider Fraud

Examples of actions by Medicaid providers which may be fraud include:

  • Billing Medicaid for doctor visits, medical procedures, drugs or supplies that are not provided to a client
  • Billing for the same service twice

Medicaid Member Fraud

Examples of actions by Medicaid 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 Medicaid card
  • Selling or buying a Medicaid 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 Medicaid to others

How You Can Help

If you suspect Medicaid fraud, waste or abuse, please report it to us immediately.

Department Efforts

  • Our Benefits Coordination Section recovers money and avoids unnecessary costs
  • Our Client Over-utilization Program works to detect and reduce over-utilization of Medicaid 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 Medicaid providers and to review possible fraud by Medicaid 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 Medicaid providers through data mining review