Or. Admin. R. 410-120-1510 - Fraud and Abuse

Fraud committed against the Oregon Health Authority’s Division of Medical Assistance Program include:

• Billing for services, supplies, or equipment that are not provided to or used for Medicaid patients;
• Billing for supplies or equipment that are unsuitable for a patient’s needs or otherwise without value;
• Claiming costs for non-covered items and services by disguising them as covered items;
• Materially misrepresenting dates and descriptions of services rendered, the identity of the individual who rendered the services or the identity of the recipient of the services;
• Duplicate billing of the Medicaid program or the recipient in a deliberate attempt to obtain additional reimbursement;
• Commissions and fee-splitting arrangements designed to obtain or conceal illegal payments.

Providers must promptly refer all suspected fraud and abuse to the Department of Justice’s Medicaid Fraud Control Unit or to the Department of Human Services’ Provider Audit Unit; providers must report suspected fraud or abuse by a client to the Department of Fraud Investigations Unit.  Providers must permit inspection, evaluation, copying and auditing of their books, records, documents, files and accounts as is required to investigate an incident of fraud or abuse.  Information obtained from providers may be shared with the MFCU and other federal and state authorities for health oversight purposes.