Fraud, Waste, and Abuse

At Parkland Community Health Plan, we are committed to safeguarding the integrity of the Medicaid and CHIP programs by actively preventing, detecting, and investigating fraud, waste, and abuse. Our Special Investigation Unit (SIU) and Payment Integrity Unit (PIU) works in partnership with providers, members, and regulatory agencies to ensure that healthcare services are delivered appropriately and that taxpayer dollars are used responsibly.

Explore this page to learn more about how you can report concerns, understand your responsibilities, and support our efforts to maintain a fair and compliant healthcare system.

What is Fraud, Waste, and Abuse:

Any act that constitutes fraud under federal or state law, including any intentional dishonesty or misrepresentation made by a person who knew the deception could cause unapproved benefit for themselves or another person.  

Any practice a sensible person would consider careless or would cause excessive use of resources, items or services. 

Any practice inconsistent with proper fiscal, business or medical practices and causes unnecessary program cost.

Fraud, Waste, and Abuse Examples by Provider:

  • A doctor billing Medicaid for X-rays, blood tests and other procedures that were never performed, or falsifying a patient’s diagnosis to justify unnecessary tests.
  • An ambulance company transporting Medicaid patients by ambulance when the patients can walk on their own and an ambulance is not medically necessary.
  • A pharmacist giving a Medicaid customer a generic drug and billing instead for the name brand version of the medication.
  • Intentionally omitting or falsely misrepresenting information about a condition, symptom, or service performed.
  • Billing for services, procedures, or supplies that were not provided or needed.
  • Preventable returns to the hospital due to inadequate discharge planning or follow-up care.
  • Providing antibiotics for viral infections or prescribing brand-name drugs when generics are equally effective.
  • Overstocking or underutilizing medical supplies, leading to expiration or unnecessary storage costs.
  • High-Cost Drug vial wasting.
  • Claims paid after Death.
  • Upcoding: Billing for a more expensive service than was actually provided (e.g., charging for a complex office visit when only a simple consultation occurred).
  • Unbundling: Submitting multiple claims for services that should be billed together at a lower rate (e.g., billing separate lab tests instead of a bundled panel).
  • Medically unnecessary services: Ordering diagnostic tests, procedures, or treatments that aren’t clinically justified, just to inflate the bill.
  • Doctor shopping: Visiting multiple providers to obtain unnecessary prescriptions (often for controlled substances).
  • Misrepresentation: Providing false information about coverage, symptoms, or treatment history to receive care or financial benefits.

Fraud, Waste, and Abuse Examples by Member:

  • Eligibility: Providing false information about income, household size, or residency to qualify for Medicaid.
  • Eligibility: Failing to report changes in income or household status that would disqualify them from coverage.
  • Medicaid Card Sharing: Allowing friends or family to use their Medicaid ID card to obtain medical services or prescriptions.
  • Doctor Shopping: Visiting multiple doctors or emergency rooms to obtain duplicate prescriptions for controlled substances (e.g., opioids).
  • Prescriptions: Selling, trading, or giving away medications paid for by Medicaid.
  • Prescriptions: Forging or altering prescriptions to get more drugs than prescribed.
  • Transportation: Scheduling non-emergency medical transportation services and then not showing up (resulting in unnecessary payments to vendors).
  • Transportation: Using transportation for non-medical purposes or lying about destinations.
  • Reselling Medical Supplies: Providing false diagnoses to a provider for the propose to obtain medical supplies/equipment for the purpose of reselling it.
  • Unnecessary ER Visits: Going to the ER for non-emergency issues (e.g., mild cold, sore throat) rather than using a primary care provider or urgent care clinic.
  • Transportation: Requesting non-emergency medical transportation (NEMT) services for short distances they could reasonably travel themselves.
  • Transportation: Using multiple rides in a day that could have been consolidated into one trip.
  • Excessive Medical Supplies: Requesting more medical supplies/equipment (e.g., diabetic strips, incontinence products) than necessary and letting them go unused or expire.
  • Excessive Appointments: Overutilizing health services by making frequent visits to multiple providers without legitimate medical need (not necessarily with intent to deceive).
  • Eligibility Changes: Not reporting eligibility changes in a timely manner even if not done maliciously, this results in abuse of benefits.
  • Medicaid Card: Not reporting a lost or stolen Medicaid card, which may be used improperly by others.
  • Prescription: Requesting early refills of prescriptions repeatedly without a valid medical reason.
  • Prescription: Stockpiling medications or manipulating symptoms to get specific drugs (even without intent to resell).
  • Transportation: Using Medicaid transportation for non-medical purposes (e.g., to visit a friend or go shopping), while billing it as a medical appointment.
  • Transportation: Misrepresenting addresses or appointment details to obtain transportation.
  • Duplicate Services: Going to different providers for the same issue without coordination of care, causing unnecessary costs to Medicaid.

Fraud, Waste, and Abuse News:

In July 2025, Texas Attorney General’s Medicaid Fraud Control Unit (MFCU), in collaboration with federal agencies, took down multiple fraudulent health care operations across Texas, including DFW‑area actors. The operation involved 30 defendants facing charges totaling around $177 million in false billing and 10 million diverted opioid pills. The schemes included illegal kickbacks totaling $1.7 million. This was part of the largest health care fraud sweep in U.S. history, with MFCU recovering over $1B since 2020

As part of the 2025, National Health Care Fraud Takedown, federal prosecutors charged four individuals in the Northern District of Texas for schemes involving over $210 million in false claims submitted to federally funded programs, including Medicaid. Local Dallas-based providers were implicated in billing for unnecessary services, unprovided items, and abusive testing practices.  Additionally, five defendants associated with one Texas pharmacy were charged with the unlawful distribution of over 3 million opioid pills. As alleged, the defendants conspired to distribute massive quantities of oxycodone, hydrocodone, and carisoprodol, which were subsequently trafficked by street-level drug dealers, generating large profits for the defendants.

In Texas Health and Human Services Commission, Office of Inspector General (OIG), Third Quarterly Report for FY2025, unauthorized use of prescriber number results in million-dollar settlement The OIG accepted a settlement agreement with two pharmacies, located in Plano and Richmond, which billed Medicaid using incorrect prescriber information. This led to 3,581 improper claims for COVID-19 test kits from January 2022 to November 2024. The provider also billed and was reimbursed for automatic refills for the test kits, which are not allowed by Medicaid policy.

How to Report Fraud, Waste, and Abuse to Parkland:

We rely on providers, members, and the public to help us identify suspicious activity that may impact the quality of care or misuse program funds. If you suspect fraud, waste, and abuse involving a healthcare provider, pharmacy, or member, we encourage you to report it. Reports can be made anonymously and are kept confidential to the extent allowed by law.

Phone: 888-212-2579

Mail: Parkland Community Health Plan
Attn: Special Investigations Unit
P.O. Box 560307
Dallas, TX 75356

Email: PCHPSIU@phhs.org

*If preferred, you may also use the attached fraud, waste, and abuse Complaint Form to submit your report by mail or email, or you can submit the form online.

View Online Form
View Fillable Form

How to Report Fraud, Waste, and Abuse to OIG & OAG:

If you suspect FWA involving a healthcare provider, facility, pharmacy, or Medicaid member, you may also report it directly to the Texas Health and Human Services Office of Inspector General (OIG) or the Texas Office of the Attorney General (OAG):

Texas OIG Fraud Hotline: 1-800-436-6184

OIG Online Reporting: https://oig.hhs.texas.gov/report-fraud

Texas OAG-MFCU: 512-371-4700

OAG-MFCU Website: https://www.texasattorneygeneral.gov

*However, we also encourage you to report suspected fraud, waste, and abuse directly to Parkland Community Health Plan. Reporting to both the state and the Health Plan helps ensure timely coordination, investigation, and resolution.

What information you will need to report Fraud, Waste, and Abuse:

To ensure a thorough review of your fraud, waste, and abuse complaint, please provide as much detail as possible. If available, refer to your Explanation of Benefits or any billing statements, which may help identify discrepancies or questionable charges.

When submitting a complaint, consider including the following information:

  • Your Full Name (you may remain anonymous, but this can assist with follow-up if needed)
  • Member ID or Medicaid/CHIP Number (if you are a member or the complaint involves a specific member)
  • Date(s) of Service in question (found on your Explanation of Benefits)
  • Name and Address of the Provider or Facility you are reporting
  • Type of Service or Item that was billed (e.g., physical therapy, mental health visit, medical equipment)
  • Reason for the Complaint describe why you believe the service is fraudulent, wasteful, or abusive
  • What You Observed or Experienced include any facts or observations about services not received, services billed incorrectly, or anything suspicious
  • Supporting Documents, if available, such as an Explanation of Benefits, medical records, appointment confirmations, or communication with the provider
  • Your Contact Information (optional but helpful for clarification or follow-up)

Your Explanation of Benefits lists services billed to your health plan and can help identify suspicious activity, such as:

  • Charges for services or visits you never received
  • Billing for the same service multiple times
  • Services billed under a different provider's name
  • Dates of service when you were not treated

If you see something on your Explanation of Benefits that doesn't look right, report it — even if you're not sure. We will investigate the concern confidentially.

Thank You, from the Special Investigation Unit!

Your vigilance helps protect valuable healthcare resources and ensures that Medicaid services remain available to those who truly need them. By reporting suspected fraud, waste, or abuse, you are supporting our efforts to maintain an ethical, accountable, and transparent healthcare system.

Together, we can safeguard the integrity of the Texas Medicaid program and promote quality care for all members.

Thank you for partnering with us in the fight against fraud, waste, and abuse.