N/A

The Fraud Investigation Unit investigates fraud and abuse within the Medicaid program by monitoring and reviewing provider billing practices, and reviewing provider records to support services billed to the program. The Fraud Investigations Unit investigates Department-wide allegations of fraud to include Medicaid providers, Welfare programs, contractors, and they conduct Department internal investigations. The Fraud Unit has out-stationed investigators to respond to the statewide investigative need. They work with other state and federal agencies to investigate and prosecute providers and clients identified as defrauding the Medicaid and Welfare programs.

Welfare Fraud
Fraud and abuse significantly impacts the welfare programs by using up valuable dollars necessary to help eligible children and adults.

Fraud and abuse is actively pursued by Fraud Investigators within Health and Welfare. They investigate allegations of fraud being committed in Idaho Child Care Program (ICCP), Food Stamps, cash, medical, WIC and energy assistance. They initiate administrative, civil and criminal action against persons who abuse or commit fraud in the various welfare programs.

What is Welfare Fraud?
Welfare fraud is any intentional action which causes a participant or provider to receive benefits to which they are not entitled.

Common Fraud Schemes
*Providing false or incomplete information to the Department at application or re-certification.
*Failing to report changes.
*Submitting a false or fraudulent document to the Department in order to get benefits.
*Transferring, hiding or giving away assets in order to be eligible to receive benefits.
*ICCP providers billing for children not seen.

Report Welfare Fraud
Fraud and abuse of public programs affects all of us. Everyone can take responsibility to report fraud and abuse. There are three ways to report fraud and abuse of taxpayer money:

1. Call toll-free at 1-866-635-7515 - the Fraud Hotline rings into 2-1-1 for initial concern documentation.
2. E-mail a fraud complaint to: welfraud@dhw.idaho.gov; or
3. Fax or mail a fraud complaint to:
Fax a complaint form at 1-208-334-0686 or
Mail to: Welfare Fraud Investigations Unit, P. O. Box 83720, Boise, ID 83720-0036
If you are filling out a form, provide us with as much detail as possible and a contact name, phone number or e-mail address. This will help us if we have additional questions regarding the information you submit.

This program is administered by the Division of Management Services, Department of Health and Welfare.

Fraud Investigators:

Reg 1. Corey Thompson 208-665-8825
Reg 2. Howard Elliot 208-799-4416
Reg 3. Paula Hisle 208-442-9946
Reg 4. Dwayne Sanders 208-334-6725 or Eileen Williams 208-334-0610
Reg 5. Randy Reese 208-235-2831or Ben Johnson 208-528-5960
Reg 6. Ben Johnson 528-5960 or Randy Reese 208-235-2831
Reg 7. Ben Johnson 208-528-5960

Contact for more information.

Accepts and reviews complaints concerning quality and appropriateness of care about member dentists.

DO NOT PROVIDE REFERRAL SERVICE!

None

A statewide Health and Welfare unit which coordinates collection efforts for over payments DHW customers may have received and assists customers in making repayment plans. Program is administered by the Division of Management Services.

Administrative Office

The goal of the Medical Care Unit is to ensure that appropriate medical services are provided in accordance with state and federal regulation, statutes, and policies.
The Medical Care Unit is responsible for the service areas listed below:
***Disease Management
***Durable Medical Equipment
***Therapy Services
***Ambulance Authorizations
***Hospice
***Surgery
***Breast and Cervical Cancer
***Vision
***Dental
***Lead Screening Program
Program is administered by the Division of Medicaid.

Available to all

The Bureau of Facility Standards serves and protects Idahoans requiring health-related services, supports and supervision in care facilities by:
*Promoting each individual's rights, well-being, safety, dignity, and highest level of functional independence;
*Enforcing compliance with state rules and federal regulations; and
*Providing information and education.
*We license and certify health care providers/suppliers following state and federal regulatory requirements, as applicable. We also conduct complaint investigations relating to these providers/suppliers.
The website has a provider/supplier list including: Ambulatory Surgery Centers,Home Health Agencies, Hospices, Hospitals, Intermediate Care Facilities for Persons with Intellectual Disabilities (ICF/ID),Long Term Care Facilities, and Rural Health Clinics. They are listed alphabetically or by region.

CNA Registry - Certified Nursing Assistant Registry is part of the Bureau of Facility Standards.

The Home Health Hotline was established for the purpose of receiving complaints or questions about local Home Health Agencies.

The Bureau is administered by the Division of Licensing and Certification.

Any intentional action which causes a participant or welfare provider to receive benefits to which they are not entitled.

Web Link to Idaho Medicaid Provider Exclusion List.

A Long Term Care Facilities design and function is to meet the health needs of two or more elderly or disabled individuals who, at a minimum, require inpatient care and services, for twenty-four or more consecutive hours.

Inpatient care is necessary for unstable or chronic health problems requiring:
•Daily professional nursing supervision and licensed nursing care
•Restorative care
•Rehabilitative care
•Assistance in meeting daily living needs

Medical supervision is necessary on a regular, but not daily, basis.

Payment Source Types:
•Skilled Nursing Facility (SNF) - Medicare-only and private pay
•Nursing Facility (NF) - Medicaid-only and private pay
•Skilled Nursing Facility & Nursing Facility (SNF/NF) - Both Medicare & Medicaid and private pay

Senior citizens and families of seniors

SHIBA is part of a network of state health insurance programs (SHIP) across the United States and its territories. In Idaho, SHIBA is funded by the Centers for Medicare and Medicaid Services (CMS), the federal agency which administers the Medicare program, and the Idaho Department of Insurance.

SHIBA is a part of the Department of Insurance, Consumer Affairs, which:

Investigates claims and insurance fraud
Provides advocacy services for consumers
Provides assistance with insurance problems or questions on life, disability, long term care, property, casualty, and health insurance
We offer free and unbiased information, counseling, and assistance regarding senior health insurance. We do not sell insurance, recommend policies, agents, or specific companies. It is our goal to provide you with up-to-date and objective information to assist you in making informed buying decisions.

Also known as SHIP - Senior Health Insurance Program.

BOISE
Toll Free 1-800-247-4422

COEUR D'ALENE
Local phone number (208) 666-6847
Toll Free 1-800-247-4422

POCATELLO
Local phone number (208) 236-6044
Toll Free 1-800-488-5764

Anyone needing assistance with Consumer Protection issues

Enforces various consumer laws, including: Consumer Protection Competition Act, Telephone Solicitation, Pay-Per-Telephone Call and Charitable Solicitation. Protects consumers, businesses and the marketplace from unfair or deceptive acts and practices - through education, mediation and enforcement, enforces and defends the state's Master Settlement Agreement with the tobacco industry

A hard copy of the complaint form can be found at the Department of Insurance web site. Print it out, fill out and mail in as instructed.

Contact for specific information.

The Medicaid Fraud Control Unit investigates and prosecutes: Allegations of Medicaid fraud by health care providers; allegations of abuse and neglect of patients in health care facilities that receive Medicaid; and allegations of misuse of patient funds by those facilities.

Provides assistance to air travelers who experience disability-related problems. Call DOT’s toll-free hotline for air travelers with disabilities 1-800-778-4838 or 1-800-455-9880 (TTY) to obtain assistance.  The hotline will provide general information about the rights of air travelers with disabilities, respond to requests for printed consumer information, and assist air travelers with disabilities with time-sensitive disability-related issues.  The hours for the hotline are 9 a.m. to 5 p.m. Eastern time, Monday through Friday, except federal holidays.

Education and Training: To improve health care quality, NCQA offers professional development to become a Patient-Centered Medical Home Certified Content Expert. See website for comprehensive knowledge of the requirements, the application process and the documentation of the NCQA PCMH Recognition Program.

Directory of Patient Centered Medical Homes (PCMH): Search by location or specialty. Also offers accreditation and training for health care plans and clinics.


Fraud Reporting: options for reporting “Falsified Document” or “Fraudulent Information” reported to NCQA.

The FDA is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nations food supply, cosmetics, and products that emit radiation. The FDA is also responsible for advancing the public health by helping to speed innovations that make medicines and foods more effective, safer, and more affordable; and helping the public get the accurate, science-based information they need to use medicines and foods to improve their health.

A variety of consumer health and safety information, including:
-Information about recalls and recall alerts
-Regulatory and business resources
-Safety education materials
-Product complaint reporting

The mission of the U.S. Department of Health and Human Services (HHS) is to enhance the health and well-being of all Americans, by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services.

Services include reporting problems with social services, etc.

Ensures that people have equal access to and receive services from US Department of Health & Human Services programs without facing unlawful discrimination, and protects the privacy and security of health information in accordance with applicable law.

• HIPAA Complaints
• Constitutional/Civil Rights Groups
• HIPAA Regulation