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Program Integrity

The Office of Program Integrity (OPI) is responsible for the prevention, detection and investigation of alleged provider fraud, waste and/or abuse. OPI collaborates with the Managed Care Contractors (MCCs), law enforcement, and various state and federal agencies to ensure regulatory compliance and accountability and protects the financial and health care service integrity of the TennCare program.

Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception or misrepresentation could result in an unauthorized benefit to an individual or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

Examples of Provider Fraud

  • Billing for services that were not provided
  • Billing for supplies that were not received
  • Billing for more expensive services or procedures than were actually performed
  • Billing more than once for the same medical service
  • Billing for services for deceased individuals
  • Unbundling, such as billing for services separately to receive a higher reimbursement rate
  • Performing medically unnecessary services
  • Services provided by unlicensed personnel
  • Falsifying documentation, for example, medical records, caretaker timesheets
  • Overprescribing
  • Dispensing generic drugs but billing for brand-name drugs
  • Giving or accepting something of value (cash, gifts, services) in return for medical services

Waste is generally understood to be overutilization, underutilization, or other misuse of resources that result in unnecessary costs to the Medicaid program and are not the result of a criminal or intentional act by the provider.

An example of waste may include a provider ordering more lab tests than determined to be medically necessary.

Abuse is the result of provider practices that are inconsistent with sound fiscal, business, or medical practices, resulting in unnecessary cost to the Medicaid program, or reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.

An example of abuse may include improper billing practices, such as misrepresenting the level of services provided in order to submit claims for a higher paying code.

Providers include doctors, nurses, dentists, nursing homes, pharmacies, medical equipment supply companies, transportation companies, counselors, home health companies or anyone else that is paid by Medicaid for health care services.

If you suspect fraud or abuse is being committed by someone who receives TennCare benefits, you may report your concerns to the Office of Inspector General in one of the following ways:

If you suspect fraud, waste or abuse is being committed by a TennCare provider (such as doctors, nurses, dentists, nursing homes, pharmacies, medical equipment supply companies, transportation companies, counselors, home health companies or anyone else that is paid by TennCare for health care services) you may report your concerns to TennCare’s Office of Program Integrity in one of the following ways:

Division of TennCare
Attn: Program Integrity Tip Department
310 Great Circle Road
Nashville, TN 37243

  • Call the Tennessee Bureau of Investigation’s Medicaid Fraud Control Division toll-free 800-433-5454

If you suspect patient abuse is being committed you may report your concerns to the Tennessee Bureau of Investigation’s Medicaid Fraud Control Division, call toll-free 800-433-5454.

  • Ask your provider questions about the services you receive and why they are needed.
  • Review your Explanation of Benefits (EOB) for accuracy of the dates of services and the services you received. If dates of service or the services billed are not accurate, report it.
  • Report any billing for equipment you never ordered or received.
  • Report shipments of medical supplies you never ordered or received.

Providers shall perform self-audit and report overpayment and, when it is applicable, return overpayment to TennCare within 60 days from the date the overpayment is identified. Overpayments that are not returned within 60 days from the date the overpayment was identified can trigger a liability under the False Claims Act. Information on how to report or refund an improper payment.