Health plans task force fight Medicaid fraud

North Carolina’s four Medicaid contractors have joined forces on what they say is the state’s first joint task force dedicated to rooting out cases of fraud, waste and abuse in the Medicaid program.

The North Carolina Association of Health Plans launched the task force in August to bring together the special investigative units and government relations staff from each of the state’s four Medicaid managed care organizations, or MCOs. These private insurance plans - AmeriHealth Caritas, Healthy Blue, UnitedHealthcare and Carolina Complete Healthcontract with the state to administer Medicaid services for millions of beneficiaries.

The purpose of the task force, organizers say, is simple: get all of the companies’ fraud investigators talking to each other. “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 formed amid heightened federal and state scrutiny of Medicaid spending in North Carolina. State lawmakers, the Department of Health and Human ServPlease see NC HEALTH3B Continued from page 1B ices and the Office of the State Auditor have all raised concerns about potential improper billing and questionable Medicaid spending. Federal regulators have signaled that they want to ‘crush” fraud in the program.

“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.

Some of those headline-making cases are homegrown.

In July, Gwendolyn Singleton, the owner of a substance abuse treatment center in Greensboro, pleaded guilty to health care fraud after she was accused of submitting more than $1.7 million worth of illicit urine drug test claims to Medicaid. She faces up to 10 years in prison, the office of N.C. Attorney General Jeff Jackson said.

More recently, on Oct. 1, Jackson’s office announced that White Oak Manor, a Burlington nursing home, 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.”

Contrary to popular memes, Medicaid fraud isn’t a problem based on individual beneficiaries. Rather, it’s providers who figure out how to game the system often to the tune of millions, or even tens of millions, of dollars.

Breaking down silos Daniel said the task force grew out of a meeting with State Auditor Dave Boliek. At Boliek’s invitation, representatives of the health plans met with state officials and demonstrated some of the tools they use to identify unusual billing patterns through data analysis.

Each of the plans has its own special investigative unit, or SIU. Those units are generally responsible for investigating suspected cases of fraud.

“Insurance companies have a long history of having special investigative units, and each company has different approaches,” Daniel said. “One company has a former detective with the Raleigh Police Department heading up their SIU unit, and others have [people with] military investigative backgrounds.”

The issue, Daniel said, is that the MCOs are technically competitors and tend to “operate in silos.”

“The SIU unit heads indicated that they would really appreciate being able to sit down with their colleagues at the other companies and share information and practices, and that was the genesis of this,” he said.

With the new task force, if one Medicaid managed care company identifies unusual billing by a provider and refers the case to the state, investigators at the other plans may be able to examine that provider’s activity in their own systems.

Each MCO often contracts with the same doctors, therapists and other providers as the others, meaning a billing pattern that appears unusual to one plan could be occurring elsewhere too. A pattern occurring with multiple companies can provide a potent clue.

The plans already alert the state to potential problems. Taylor Griffin, senior policy adviser for Medicaid at the association of health plans, said quarterly reports from the plans show hundreds of referrals involving potential provider or organizational billing issues over the years.

“There have been some alleged people in North Carolina where members were telling their care managers that this person was compelling them to allow them to fraudulently bill their Medicaid claims in exchange for certain things like housing and other remuneration,” Griffin said.

Cases can also surface through data analysis. For example, a plan may identify a provider whose billing records show repeated claims for services that don’t jive with electronic visit verification records, which are intended to document when and where certain services were delivered.

Other potential red flags include duplicate claims or claims for services that appear unlikely to have occurred.

“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 is not limited to any particular type of Medicaid service, Daniel said. Instead, investigators will look across the program for what the plans call anomalies unusual patterns that warrant additional investigation.

Autism therapy under the microscope One Medicaid-covered service has garnered particular scrutiny in recent months.

Applied behavior analysis, a therapy designed to help children with autism build communication and daily living skills through intensive one-on-one interventions, is one of the fastest growing areas of Medicaid spending in North Carolina and across the country.

State and federal Medicaid spending on ABA in North Carolina exploded over a five-year period, surpassing $505 million in 2025, up from just $1.9 million in 2020. Costs are projected to exceed $1 billion by 2027, according to the N.C. Department of Health and Human Services.

That surge in spending ‘‘far outpaces increases in Autism Spectrum Disorder diagnosis” and cannot “‘be explained by increased access alone,” according to NCDHHS.

The number of beneficiaries receiving ABA in North Carolina grew from 8,704 people in 2024 to 13,447 in 2025, an increase of about 54 percent. In just that year, Medicaid spending on the therapy swelled by 65 percent, with the program paying an average of nearly $37,600 per patient.

“If you look at the growth in the expenditure for ABA therapy, it deserves to be flagged as a potential source of fraud,” Jackson told the House Select Committee on Oversight and Reform earlier this year.

A bill signed into law by Gov. Josh Stein in April imposes restrictions on the therapy in an effort to rein in the spending and prevent improper billing. Among other things, it allows Medicaid managed care plans to take steps to close their networks to providers suspected of fraud under certain circumstances.

“We felt like we needed a central way to collaborate now that some of the laws have changed,” Griffin said, adding that the autism treatment is one of the task force’s “biggest areas of concern.”

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