North Carolina Medicaid fraud task force launched by four health plans

NC's four Medicaid managed care organisations have formed the state's first joint fraud task force. The initiative targets billing fraud worth millions of dollars.

North Carolina's first joint Medicaid fraud task force targets billing abuse worth millions

North Carolina's four Medicaid managed care organisations have created what northcarolinahealthnews.org describes as the state's first joint task force dedicated to rooting out fraud, waste and abuse in the Medicaid programme.

The North Carolina Association of Health Plans launched the task force in August, bringing together the special investigative units and government relations staff from AmeriHealth Caritas, Healthy Blue, UnitedHealthcare and Carolina Complete Health — the four private insurers contracted by the state to administer Medicaid services for millions of beneficiaries.

"There was a desire, especially on the part of the special investigative unit leaders, to have a forum where they could share information among themselves, and that was the birth of the idea," said Peter Daniel, executive director of the association.

The task force was established amid heightened scrutiny of Medicaid spending at both state and federal level. North Carolina's General Assembly, the Department of Health and Human Services and the Office of the State Auditor have all raised concerns about improper billing and questionable expenditure. Federal regulators have signalled that they intend to "crush" fraud in the programme.

"Fraud, waste and abuse has been in the news all over the country, and we've been seeing egregious examples of fraud, waste and abuse on the news most every night," Daniel said.

Recent fraud cases illustrate the scale of the problem

Several high-profile cases in North Carolina have underscored those concerns. In July, Gwendolyn Singleton, the owner of a substance abuse treatment centre in Greensboro, pleaded guilty to health care fraud after being accused of submitting more than $1.7 million in illicit urine drug test claims to Medicaid. She faces up to ten years in prison, according to the office of Attorney General Jeff Jackson.

On 1 October, Jackson's office announced that White Oak Manor, a nursing home in Burlington, had agreed to pay the state $98,474 after the facility allegedly hired an unqualified person as a nurse and then billed Medicaid for services she provided.

Experts note that Medicaid fraud is predominantly a provider-driven problem, not one rooted in individual beneficiaries. Providers who exploit billing systems can accumulate fraudulent claims running to millions — or even tens of millions — of dollars.

Investigators breaking out of silos

Daniel said the task force grew out of a meeting with State Auditor Dave Boliek. At Boliek's invitation, health plan representatives met with state officials and demonstrated tools used to identify unusual billing patterns through data analysis.

Each of the four plans already operates its own special investigative unit, or SIU. Those units are responsible for investigating suspected fraud cases and bring varied expertise: one plan is headed by a former detective from the Raleigh Police Department, while others draw on personnel with military investigative backgrounds.

The core problem, Daniel explained, is that the MCOs are technically competitors and have historically "operated in silos." Under the new arrangement, if one plan identifies unusual billing by a provider and refers the case to the state, investigators at the other plans can examine that provider's activity within their own systems.

Because each MCO often contracts with the same doctors, therapists and other providers, a suspicious billing pattern spotted by one plan may be occurring across multiple companies — a cross-plan pattern that can serve as a powerful indicator of systemic fraud.

Data analysis and red flags

Taylor Griffin, senior policy adviser for Medicaid at the association, said quarterly reports from the plans already show hundreds of referrals involving potential provider or organisational billing issues. Some cases have emerged through direct member reports: beneficiaries told their care managers that providers were compelling them to allow fraudulent billing of Medicaid claims in exchange for housing or other remuneration.

Data analysis provides another detection route. A plan may identify a provider whose billing records repeatedly show claims for services that do not match electronic visit verification records — the system designed to document when and where certain services were delivered. Duplicate claims or claims for services that appear implausible are also flagged as potential red flags.

"If a provider is constantly billing claims twice, maybe their computer system is messed up — or maybe they're trying to execute fraud," Griffin said. "You may try to work with a provider to determine what's actually going on."

The task force covers the full scope of Medicaid services rather than focusing on any single area, Daniel said. Investigators will look across the programme for what the plans call anomalies — unusual patterns that warrant further examination.

Applied behaviour analysis under particular scrutiny

One Medicaid-covered service has attracted heightened attention in recent months. Applied behaviour analysis — a therapy designed to help children with autism develop communication and daily living skills through intensive one-on-one intervention — is one of the fastest-growing areas of Medicaid spending in North Carolina and nationally.

Combined state and federal Medicaid spending on applied behaviour analysis in North Carolina surpassed $505 million in 2025, up from just $1.9 million in 2020 — a rise that played out over five years. Costs are projected to exceed $1 billion by 2027, according to northcarolinahealthnews.org's reporting on programme data.

Source: Google News MT — Crime (en)