The Enforcement division's Medicaid Provider Integrity section is responsible for the investigation of activities relating to the prevention, detection, and investigation of provider waste, abuse and fraud in the Medicaid and Children's Health Insurance Program (CHIP).

The sector works closely with the Office of Chief Counsel division's Sanctions section to recover Medicaid overpayments and penalties; and if necessary, exclude providers from the Medicaid program.

The Medicaid Provider Integrity section also refers cases of potential criminal fraud to the Office of the Attorney General's Medicaid Fraud Control unit.

Waste, abuse and fraud can take many forms. Examples include:

• Billing for services not provided
• Reporting a higher level service than was actually performed. This is often called "up-coding"
• Submitting a claim under one patient's name when services were actually provided to another person
• Altering claim forms and patient records
• Billing for non-covered services as if they were covered services
• Changing the date of service on a claim form so it falls within a patient's benefit period; and/or
• Performing services that are not suitable or medically necessary.

Concerned citizens, providers (e.g., doctors, dentists, counselors, etc.), Medicaid recipients and others can help prevent cases of waste, abuse and fraud by notifying the Medicaid Provider Integrity section.

If you suspect waste, abuse or fraud in the Medicaid system, complete our Online Complaint Form. If you prefer to work offline, download the paper version of the online complaint form or contact the fraud hotline at 800-436-6184. You can also mail your complaint to:

Texas Health and Human Services Commission
Office of Inspector General/Medicaid Provider Integrity
Mail Code 1361
P. O. Box 85200
Austin, TX 78708-5200