Harrisburg, PA – According to a recent report from the United States Department of Health and Human Services, Pennsylvania is number one nationally in the number of Medicaid fraud charges filed against bad actors, and third overall in convictions secured. This success is only possible because of the hard work of the dedicated staff at the Department of Human Services (DHS), which operates a comprehensive fraud prevention and detection system to preserve Medicaid resources for people who need it and helps to reclaim taxpayer funds.   

This work plays a central role in making referrals to law enforcement that allow potential fraud to be prosecuted. 

“As DHS builds bridges to health and stability for eligible Pennsylvanians through Medicaid and our other supportive programs, we must be sure that taxpayer dollars are being used as intended and be vigilant in protecting these critical resources,” said DHS Secretary Dr. Val Arkoosh. “DHS staff closely monitor our programs using a variety of tools to quickly identify potential fraud and abuse. This work is the basis for legal action taken by our partners at the Pennsylvania Office of Attorney General, and I am proud of our contribution to making Pennsylvania a national leader in prosecuting bad actors and protecting these essential programs for Pennsylvanians.” 

To weed out fraud, DHS staff verify each applicant’s information against 12 data bases to ensure proper income eligibility during application and renewal. Applications or cases that are flagged for potential misinformation are referred to the Office of State Inspector General for further investigation. In State Fiscal Year 2023-24, the OSIG investigated more than 19,000 applications for public assistance benefits – the vast majority of which came from DHS’ referrals.  

“As Attorney General, combating Medicaid fraud was a critical priority, and it is gratifying to know that this work has safeguarded Pennsylvanians while holding criminals accountable,» said State Inspector General Michelle Henry. «As Inspector General, I am proud to continue this mission in partnership with DHS. Our dedicated agents work to investigate and prevent fraud, ensuring the integrity of public assistance programs and protecting these vital resources for those who truly need them.”

In addition to extensive verifications of people applying for benefits, DHS’s Bureau of Program Integrity (BPI) works to prevent fraud, waste, and abuse by monitoring and verifying proper use of the program by Pennsylvanians with Medicaid coverage and by providers offering care and services through Medicaid. 

BPI’s staff work to ensure proper use of public funds through a multifaceted approach, including:  

• Providing education and technical assistance to help providers operate in line with state and federal Medicaid program requirements. 
• Medicaid is a payor of last resort, so BPI staff review Medicaid cases to determine whether other payment sources like commercial or employer-sponsored insurance or Medicare are more appropriate options for payment of Medicaid claims and works with these organizations to recover payments.
  • For the 2023-24 State Fiscal Year, this work resulted in nearly $500 million in fund recovery or cost avoidances.  
• Taking action against providers who violate program requirements or are identified to be on a federal Do Not Pay List.
  • In the 2023-24 State Fiscal year, 325 providers were terminated from the Medicaid program for cause, leading to $33.7 million in savings to the Medicaid program.  
• Leveraging Fraud Capture technology – an AI-driven system that analyzes Medicaid program data to identify potential outliers for further investigation and additional follow-up by BPI staff. 

When this work results in cases of suspected Medicaid fraud, staff from the Bureau of Program Integrity make referrals, as appropriate, to other state and federal entities for further action. This work includes referring suspected fraud to the Office of Attorney General’s Medicaid Fraud Control Section, who then uses BPI’s work and investigation to take additional steps to pursue criminal action against people who may be abusing the Medicaid program and resources.  

To report suspected fraud or abuse of programs like Medicaid and other DHS public assistance programs:  

• Call 1-844-DHS-TIPS (1-844-347-8477), or  

Submit a completed form: MA Provider Compliance Hotline Response Form