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.
- 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