Reporting Fraud, Waste and Abuse

You trust that your doctor, caregiver or loved one will take care of you. You believe they will always have your best interests in mind. Sometimes, when someone helps take care of you, they can take advantage of you. It is important to recognize the signs of neglect, abuse and fraud. If this happens, it is important to report it. This allows you to be safe and get the care you need.

Neglect occurs when someone fails to provide or withholds the necessities of life from you. This includes food, clothing, shelter, or medical care.

Abuse means causing any physical, sexual or mental injury to you. This can also be taking advantage of your financial resources.

• Physical abuse. Any inappropriate contact that causes bodily harm. For example, being slapped, scratched, or pushed. Being threatened with a weapon, such as a knife or a gun, is another example.
• Sexual abuse. Any sexual behavior or intimate physical contact that occurs without your permission. This can be touching your genital area, buttocks or breasts.
• Mental abuse. When you feel emotional distress resulting from the use of demeaning or threatening words. This can also include signs, gestures and other actions. For example, controlling behavior, embarrassment or social isolation are types of mental abuse.
• Financial Abuse. When someone uses your money without your consent. This includes improper use of guardianship or power of attorney.

“Fraud” means to knowingly get benefits or payments that you are not entitled to receive. Please let us know if you are aware of someone who is committing fraud. This could be a provider or a member. Some examples of healthcare fraud include:

• A lie on an application
• Using someone else’s ID card
• A provider (doctor) billing for services that were not done
• Transportation (usage abuse)

Report fraud in the Medical Assistance Program by contacting the Pennsylvania Department of Human Services. Call 1-866-379-8477 (TTY), 8:30 a.m. to 3:30 p.m. EST, Monday through Friday.

To report waste, abuse, or fraud, gather as much information as possible.

When reporting about a provider  (a doctor, dentist, counselor, etc.) include: 

• Name, address, and phone number of provider
• Name and address of the facility (hospital, nursing home, home health agency, etc.)
• Medicaid number of the provider and facility, if you have it
• Type of provider (doctor, dentist, therapist, pharmacist, etc.)
• Names and phone numbers of other witnesses who can help in the investigation
• Dates of events 
• Summary of what happened

When reporting about someone who gets benefits, include: 

• The person’s name
• The person’s date of birth, Social Security Number, or case number if you have it 
• The city where the person lives 
• Specific details about the waste, abuse, or fraud