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Reporting Fraud, Waste and Abuse

Peach State Health Plan is serious about finding and reporting times that Georgia Medicaid funds are used in the wrong way. This is called waste, fraud or abuse.

“Fraud” means to get benefits or payments you are not supposed to get. This could be a provider or a member. Some examples of fraud include:

  • Lying on an application
  • Using someone else’s ID card
  • A doctor charging your insurance for services that were not done

Waste is the overuse of services that may result in costs not needed for health care benefits. This includes direct costs and indirect costs. Waste usually results from the misuse of services.

Abuse is anything that causes you physical, sexual or mental harm. This can also be using your money without your permission.

  • Physical abuse. Any contact that you do not want that causes harm to your body. For example, being slapped, scratched or pushed.
  • Sexual abuse. Any sexual contact that you do not want. This can be touching your genitals, buttocks or breasts.
  • Mental abuse. When you feel distress because of another person’s words, gestures, or actions. For example, when someone controls you, embarrasses you, or keeps you from seeing your family.
  • Financial Abuse. When someone uses your money without your permission. This includes improper use of guardianship or power of attorney.

You trust your doctor, caregiver or loved one to take care of you. You believe they will always do what is best for you. Sometimes, when someone takes care of you, they can take advantage of you. It is important to know the signs of neglect, abuse and fraud. If this happens to you or a loved one, you should report it. This allows you to be safe and get the care you need.

Neglect occurs when someone does not provide or takes away things that you need to live. This includes:

  • Food
  • Clothing
  • Shelter
  • medical care

If you believe that you are being taken advantage of or hurt by someone, report it. All information will be kept private. Stopping fraud and abuse will help protect you. It will also provide more time and money for your healthcare needs.

There are many ways to report fraud and abuse:

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

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

  • Name, address, and phone number of provider
  • Medicaid number of the provider and facility, if you have it
  • Tell us what kind of provider they are (a doctor, dentist, therapist, etc.)
  • Names and phone numbers of other witnesses
  • Dates of events 
  • Details 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 
  • Details about the waste, abuse, or fraud