Medicaid Fraud, Abuse and Neglect

What is the Colorado Medicaid Fraud, Abuse & Neglect Unit (MFANU)?

Mission

The Medicaid Fraud, Abuse & Neglect Unit (MFANU) is dedicated to protecting the most vulnerable members of our community from abuse, neglect, and exploitation in Medicaid-funded healthcare settings. We work tirelessly to investigate and prosecute those who harm or take advantage of Medicaid recipients, ensuring that they receive the safe, ethical, and high-quality care they deserve.

In addition to safeguarding patients, our unit is committed to detecting and preventing fraud by healthcare providers who misuse Medicaid funds. By holding wrongdoers accountable, we protect taxpayer dollars and help maintain the integrity of essential healthcare services.

Through strong partnerships with federal, state, and local agencies, we strive to uphold justice, promote accountability, and create a safer healthcare system for all. Our mission is to ensure that Medicaid resources serve those in need while protecting beneficiaries from harm and exploitation.

The Medicaid Fraud, Abuse & Neglect Unit

The Medicaid Fraud, Abuse & Neglect Unit (MFANU) is staffed by a team of up to 28 attorneys, investigators, analysts, and auditors trained in the complexities of healthcare fraud investigation and litigation.

We work closely with United States Attorneys, District Attorneys, Federal and State law enforcement agencies, managed care organizations, and other state and federal agencies. Our investigations can result in criminal charges against healthcare providers, as well as civil actions to recover overpayments, treble damages, and civil penalties.

In State Fiscal Year 2024, the MFANU received 435 complaints and referrals of suspected fraud, patient abuse or neglect. The Unit opened 172 matters for initial investigation, received restitution orders in criminal cases totaling $704,467.07, and collected $65,403.58 in criminal restitution to pay back the Colorado Medicaid program. In addition to criminal prosecutions, the Unit obtained civil settlements totaling $2,253,156.13 and collected over $1,285,327.68, to pay back fraud.

The Colorado MFANU receives 75 percent of its funding from the U.S. Department of Health and Human Services under a grant award totaling $3,858,544.00 for Federal fiscal year (FY) 2025. The remaining 25 percent, totaling $1,286,181.00 for FY 2025, is funded by the State of Colorado.

What categories of cases does the MFANU pursue?

Fraudulent conduct by Medicaid providers and individuals involved with providing Medicaid services.
The abuse, neglect, and exploitation of individuals in health care facilities that receive Medicaid funds or in board and care facilities.
The recovery of Medicaid overpayments identified in the investigation of fraud, patient abuse and neglect, and financial exploitation of clients.

Types of Medicaid cases

Medicaid Fraud occurs when a Medicaid provider or supplier knowingly:

Bills Medicaid for a service or product not actually provided to the patient
Uses an improper code to bill Medicaid for a higher priced service or product when a lower priced service or product was provided
Bills Medicaid for non-covered services by describing them as covered services
Misrepresents a patient’s diagnosis or condition and/or bills Medicaid for a service or product that is not medically necessary
Falsifies medical records or supporting documentation
Receives or gives a kickback (money or some other thing of value) for referral of a Medicaid patient for medical services or products
Falsifies a physician’s certificate of medical necessity
Bills Medicaid for drugs dispensed without a lawful prescription
Creates false employee time sheets and bills Medicaid for services not rendered

Types of patient abuse, neglect and exploitation cases

When any provider or employee of a Medicaid-funded facility (i.e., nursing home, rest home, or state hospital) physically assaults any resident, the MFANU can investigate. We investigate abuse whether or not it leads to serious injury, and even if the patient is not a Medicaid recipient. We also investigate physical abuse of Medicaid patients by caregivers in settings other than nursing homes.

Physical or sexual assaults
Unlawful use of restraints or confinement
Failure to provide medical care
Failure to ensure that a patient’s basic needs are met
Failure to monitor patient status
Misuse of patient funds

Signs of Medicaid Fraud & Abuse

Fraud

The provider bills Medicaid for, or the patient is pressured to receive, unnecessary or excessive services, products, or tests.
The provider bills Medicaid for services, products, or tests not documented in a patient’s file.
The provider alters or fabricates a patient’s medical records or other supporting documentation.
The provider claims to provide services, products, or tests for free.

Physical Abuse

The resident has bruises, welts, lacerations, broken bones or burns.
The resident’s injuries are inconsistent with the explanation of the injuries.
The resident develops a significant unexplained change in behavior and becomes fearful, mistrustful, withdrawn, or agitated.

Exploitation

The facility does not maintain a ledger of the resident’s personal spending.
The facility does not maintain residents’ personal funds in a bank account separate from the facility’s operating account. (Note that the residents’ funds may be kept together in one bank account.)
The ending balance in the facility’s ledger showing the residents’ personal spending does not match the ending balance in the bank statement for the residents’ personal funds bank account.
Large sums of money are withdrawn without the resident’s knowledge.
Funds are spent to purchase items of no use to the resident.

Reporting Medicaid Fraud, Abuse & Neglect

Why Report Medicaid Fraud & Abuse?

Medicaid fraud should be reported because Medicaid payments are made from taxpayer funds. When Medicaid funds are fraudulently taken or stolen, that money is no longer available to help deserving patients: it cheats both recipients and taxpayers.

Patient abuse and the stealing or commingling of Medicaid recipient funds should be reported because it exploits our most vulnerable adults.

Criminal convictions can deter fraud and abuse. Civil lawsuits can recover money that can be returned to the Medicaid program to help recipients.

Which People Or Companies Do I Report?

Report any Medicaid provider you suspect has committed fraud or abuse. A Medicaid provider includes any individual, corporation, or other entity paid by Medicaid for providing a health care service. It also includes their officers and employees.

Medicaid providers can include: adult care homes, ambulance and transportation companies, behavioral healthcare providers, chiropractors, community care service providers, dentists, home health agencies, hospitals, laboratories, medical equipment and supplies companies, nurses, nurse aides, nursing homes, pharmaceutical companies, pharmacies, physicians, physical therapists, podiatrists, psychiatrists, psychologists, social workers, speech therapists, and others.

Is There Protection for Whistleblowers?

State and Federal laws provide protection to employees who report fraud or abuse.

Where to Report Fraud, Abuse or Neglect

Report Medicaid provider fraud or patient abuse to the Colorado Attorney General’s Medicaid Fraud, Abuse & Neglect Unit online or at (720) 508-6696.

Important notice: The Attorney General’s Office does not have authority to provide legal advice or legal representation to individuals and does not have the authority to investigate or prosecute your individual case.

Medicaid recipient fraud (fraud by those being served by Medicaid, including fraudulent eligibility and transfer of assets) should be reported to the Colorado Department of Health Care Policy & Financing (HCPF):

Submit online Health First Colorado Provider Fraud Form
Call toll free at 855-375-2500 (for State Relay, call 711)
Send an email to hcpf_reportproviderfraud@state.co.us

To report Medicare fraud, contact the Office of Inspector General, US Department of Health and Human Services, at (800) 447-8477.

To report private insurance fraud, contact the Colorado Attorney General’s Financial Fraud Unit at https://coag.gov/file-complaint/insurance-fraud/ or make a complaint at https://coag.gov/file-complaint/.

To report fraud and abuse in state licensed facilities, agencies and nursing comes, contact the Colorado Department of Public Health & Environment (CDPHE).

Tips on submitting a complaint

The more information you can provide about the situation, the more useful your complaint will be. If possible, be prepared to provide the following information:

Click here to locate your district attorney’s office (opens an external website in a new window).