Georgia Medicaid Fraud, Waste, Abuse, and Program Integrity Guide

A letter demanding repayment of past Medicaid benefits is, for most Georgia families, their first and only brush with program integrity. It can also arrive as a parent's nursing home that is suddenly dropped from Medicaid, or a personal care aide who keeps billing for visits she never made. Georgia Medicaid program integrity is the machinery, run by two state agencies under federal rules, that audits providers, screens who is allowed to bill, and investigates fraud. For most people it stays in the background. This guide explains how it works and, when it does reach your family, exactly what to do, who to call, and what your rights are.

In This Guide

• How Georgia Medicaid program integrity works
• The two agencies behind Georgia Medicaid program integrity
• You got a Medicaid overpayment letter
• Your provider was excluded or shut down
• How to report Medicaid fraud for free
• Protecting your Medicaid number from identity theft
• Whistleblowers and qui tam suits
• Learn More

How Georgia Medicaid program integrity works

Program integrity is the set of controls that polices how Medicaid money is spent. Federal law sets the framework; Georgia runs the day-to-day work. The system splits roughly into three jobs: screening providers before they can bill, auditing claims after the fact, and investigating and prosecuting fraud.

The words fraud, waste, and abuse are not interchangeable. Fraud means knowingly submitting false claims, such as billing for a home visit that never happened. Abuse means billing practices that waste money without proven intent to deceive, such as charging for services that were not medically necessary. Waste means inefficient overuse of resources without any abusive intent. Each is handled with a different tool, and only fraud carries criminal exposure.

For a family, the practical point is simpler. Program integrity reaches you in one of three ways, and the rest of this guide walks through each: a notice asking you to repay benefits, a provider who disappears after an exclusion or a raid, or your own decision to report someone who is cheating the program.

The two agencies behind Georgia Medicaid program integrity

Two separate Georgia offices do this work, and they handle different problems.2

The Georgia Department of Community Health (DCH) is the state Medicaid agency, and the program-integrity work that happens inside the agency belongs to it: enrolling and screening providers, auditing claims, and recovering overpayments. DCH is also the agency that handles Medicaid recipient fraud, meaning fraud by members rather than providers, and those cases are prosecuted by your local district attorney.2

Georgia's Medicaid Fraud Control Unit (MFCU) is housed in the Office of the Attorney General, the Georgia Department of Law, and, as of 2026, operates as the Medicaid Fraud and Patient Protection Division. Under the federal rules that govern every state MFCU (42 CFR Part 1007), it investigates and prosecutes Medicaid provider fraud and reviews complaints of abuse or neglect of patients or residents in health care facilities that receive Medicaid payments. Its work is aimed at providers, not members: recipient fraud is handled by DCH and prosecuted by the local district attorney. You can reach the division at (404) 458-2878, ext. 664, Monday through Friday from 8:30 a.m. to 5:00 p.m., or through its online Medicaid Fraud and Patient Abuse Complaint Form.2

You got a Medicaid overpayment letter

A letter saying you owe Medicaid money back is alarming, but it is usually not an accusation of crime. Most member overpayment notices trace to an eligibility or income error, not fraud, and many are at least partly wrong.

The common cause is income that was never reported or was reported late. When countable income rises above the Medicaid limit, the agency can find that benefits were paid in months the member was over the limit. This is also where the spend-down rules matter: under the medically needy pathway, the agency deducts incurred medical expenses from income, and the income is measured over budget periods of no more than six months, so a member who looks over the limit across a long stretch may actually have been eligible in several of those months.4

Three steps protect you.

Do not ignore the letter. Missing the hearing deadline can forfeit your appeal and let the demand stand by default.

Your provider was excluded or shut down

Sometimes the disruption is not a letter but a vanished provider: a nursing home dropped from Medicaid, or a home health agency that closes after an investigation. When federal regulators exclude a provider, that provider can no longer bill any Medicaid or Medicare program, and members have to move to a new one.

If the provider is your parent's nursing home, federal rules protect the resident during a transfer: the facility must give advance notice, prepare a discharge plan, help arrange a safe new placement, and cannot simply turn the resident out. Georgia's long-term care ombudsman advocates for residents in exactly these situations and can sit in on discharge planning at no cost.

If the provider is a home health, personal care, or other community agency, call your Medicaid managed care plan first; the plan must help you find a replacement and keep your care going. Practical steps: ask for your medical records before they become hard to obtain, get the new provider authorized quickly, and keep receipts for anything you pay out of pocket during the gap.

How to report Medicaid fraud for free

Search results for reporting Medicaid fraud are dominated by law firms advertising whistleblower rewards. You do not need a lawyer, and you do not need to file a lawsuit, to report fraud. Each of these channels is free, and you can report anonymously.

If your personal care aide is billing for hours she did not work, the Medicaid Fraud Control Unit is the right line, because provider fraud is exactly what it investigates and prosecutes. Reporting a provider is not a report about you: the division's job is provider fraud and patient abuse, and recipient fraud is handled by DCH and prosecuted by the local district attorney.2

Protecting your Medicaid number from identity theft

Medical identity theft happens when someone uses your benefit number to bill the program for care you never received. The routine federal guidance sets out for Medicare beneficiaries is the one to copy: protect the number like a credit card, give it only to health care providers, insurers, or people you trust who work with the program, and compare the dates and services on the statements you receive against the care you actually got.3 The same discipline is what protects a Medicaid number.

If you spot charges for services or equipment you never received, or you believe your number was stolen, report it immediately to DCH and to law enforcement, and keep monitoring your statements. You are generally not liable for fraudulent claims billed by someone else, but documenting the theft early protects your record and your continued eligibility.3

Older adults are a heavy target for the broader fraud economy this sits inside. In calendar year 2025, victims over 60 reported more than $7.7 billion in losses across over 201,000 complaints to the FBI's Internet Crime Complaint Center, and the Federal Trade Commission found that total fraud losses reported by adults 60 and older rose from about $600 million in 2020 to $2.4 billion in 2024. Both are reported-loss totals, and elder fraud is widely underreported, so the real harm is larger. Government-imposter scams, in which a caller pretends to be from Medicare or another federal agency, are among those that hit seniors hardest, and a real federal agency will never call to demand payment by gift card, wire transfer, or cryptocurrency.7

Whistleblowers and qui tam suits

A whistleblower lawsuit, called a qui tam case, lets a private person sue on behalf of the government over fraud and share in any money recovered. That is the path the advertising law firms are selling. It is real, but it is the heavy machinery, meant for large-scale provider fraud, and it can take years under court seal while the government investigates.

For most families, the free hotline report above is the right tool, not a lawsuit. Reporting to the Medicaid Fraud Control Unit or the HHS Office of Inspector General costs nothing, needs no lawyer, and can be done anonymously. Federal and Georgia law also protect employees from retaliation for reporting or investigating fraud. If you have direct knowledge of a major billing scheme, that is the situation where consulting a whistleblower attorney about a qui tam case can make sense; for a single bad aide or a suspicious bill, start with the hotline.

Learn More

Find personalized help understanding a Medicaid notice at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.