DHS takes seriously our responsibility to improve the health and quality of life for the Pennsylvanians we serve through the many programs we administer, such as Medicaid.
We must be good stewards of public resources so that we can continue this work. Fraud prevention, detection, and program integrity are a core part of DHS’ efforts to protect the essential programs we oversee and the people who use these services.
Fraud, abuse, and misuse of public assistance programs can take on many forms, and DHS staff monitor for and review potential fraud and abuse and, when necessary, make referrals to law enforcement and licensing agencies for further investigation and prosecution. DHS also works to recover misallocated public funds or, when possible, avoid potential Medicaid costs altogether by billing other available coverage.
Eligibility Fraud
When a person applies for a public assistance program, information about the applicant and their income and household must be provided to determine eligibility for benefits.
DHS staff verify each applicant’s information against databases to ensure proper eligibility during application and renewal, including:
- Department of Labor & Industry wage and unemployment;
- Social Security Administration beneficiary and earnings;
- Social Security and Immigration systems to determine citizenship and residency status;
- Internal Revenue Service and Pennsylvania Department of Revenue income and earnings;
- Verification with other state public assistance agencies, among others;
- Lottery winnings; and
- Deceased persons match check with the Pennsylvania Department of Health, managed care organizations, and the Social Security Administration.
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. OSIG staff are also located in DHS’ County Assistance Offices to enhance coordination between the agencies.
Medicaid Fraud
In addition to extensive verifications of benefits applications, DHS’ Bureau of Program Integrity works to prevent fraud, waste, and abuse by monitoring and verifying proper use of the Medicaid program (called Medical Assistance in Pennsylvania) by individuals covered by Medicaid and providers offering care and services through the program.
To ensure Medicaid resources are used as intended, BPI staff:
Leverage Fraud Capture technology – a system with AI capabilities that analyzes Medicaid program data to identify potential outliers for further investigation and additional follow-up by BPI staff; and,
Take action against providers who violate program requirements or are identified to be on a federal exclusion list.
Provide education and technical assistance to providers who are enrolled in Medicaid to help them operate in line with state and federal Medicaid program requirements;
When fraud or program misuse is suspected, BPI works with the Pennsylvania Office of Attorney General and other state and federal oversight and law enforcement agencies to pursue criminal investigations and professional recourse.
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, and resulting in a report from the United States Department of Health and Human Services naming Pennsylvania as a national leader for prosecuting and obtaining convictions in cases of Medicaid fraud. BPI’s monitoring and investigatory work makes referrals that provide the foundation for the Attorney General’s Medicaid Fraud Prevention Unit’s success on behalf of Pennsylvania taxpayers.
Other Program Integrity Work
The Bureau of Program Integrity also works to ensure that Pennsylvania is closely adhering to national Medicaid policy.
Medicaid is a payor of last resort, which means that BPI staff conduct third-party liability reviews of 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. BPI staff then works with these organizations to recover payments.
BPI’s work resulted in nearly $500 million in fund recovery or cost avoidances for the 2023-24 State Fiscal Year.
States are also required to identify, when possible, whether other health coverage is available through an employer and assisting with those costs when it will result in a cost savings for Pennsylvania compared to the cost of Medicaid coverage. This is checked during the Medicaid application process.
Pennsylvania’s Health Insurance Premium Payment program is among the most productive in the nation, saving almost $112 million in taxpayer resources in State Fiscal Year 2023-24.
Report Public Benefits Fraud
You can help protect public assistance resources for those who need it by reporting suspected fraud or abuse of public assistance programs like Medicaid, SNAP, and others.