What is a credible allegation of fraud?

CMS provides certain bounds around the definition of “credible allegation of fraud” at 42 C.F.R. § 455.2:

Generally, a “credible allegation of fraud” may be an allegation that has been verified by a State and that has indicia of reliability that comes from any source. A credible allegation of fraud, for example, could be a complaint made by an employee of a physician alleging that the physician is engaged in fraudulent billing practices, i.e., the physician repeatedly bills for services at a higher level than is actually justified by the services rendered to beneficiaries.

Upon the Utah Office of Inspector General (UOIG) review of the physician’s billings, the UOIG investigator may determine that the allegation has indicia of reliability and is, in fact, credible. Indicia of reliability means that there are signs, indications or circumstances that point to the existence of a given fact. If there are signs, indications or circumstances that seem to point to the existence of fraud, there is a credible allegation of fraud. The Medicaid fraud allegation tends to indicate it is probable.

When UOIG identifies a credible allegation of fraud or “potential criminal conduct, relating to Medicaid funds or the state Medicaid program” we refer the case to the Medicaid Fraud Control Unit (MFCU) or to law enforcement. Learn more by reading the CFR, CMS guidelines and the Utah OIG statute:

https://le.utah.gov/xcode/Title63A/Chapter13/63A-13.html?v=C63A-13_1800010118000101