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Medicaid Program Integrity Section is Not Cost-Effectively Identifying and Preventing Fraud, Waste, and Abuse (November 2016)


The Program Integrity (PI) Section of North Carolina’s Medicaid program is charged with detecting and preventing fraud, waste, and program abuse, and ensuring that taxpayer dollars are used appropriately. The Program Evaluation Division found that due in part to a lack of access to valid and reliable claim payment data, the number of fraud referrals made by the PI Section has declined in recent years. Additionally, the lack of a formal risk assessment process and performance management information has limited the Section’s cost-effectiveness. Finally, the PI Section is neither effectively monitoring Medicaid recipient eligibility determinations nor effectively utilizing available information gleaned from reviews of eligibility determinations and medical service claims. The General Assembly should amend state law to adopt a uniform methodology to measure the severity of errors; provide incentives for county social services departments to ensure accuracy of eligibility determinations; require the identification of alternatives to increase amounts recouped from overpayments and percentage of fraud referrals accepted; develop a corrective action process for providers selected for enhanced oversight; and produce an annual performance report and work plan.

Final Report

Executive Summary



Relevant Legislation:

Press Coverage:

PED Contact:

Program Evaluation Division, North Carolina General Assembly
Legislative Office Building, Suite 100
300 North Salisbury Street , Raleigh, NC 27603-5925