CARE WITH ACCOUNTABILITY
Protecting Medicaid Resources for Those Who Need Them Most
The Oklahoma Health Care Authority (OHCA) takes program integrity very seriously. With more than 1 million Oklahomans relying on Medicaid (SoonerCare) programs, safeguarding taxpayer funds from fraud, waste and abuse is a high priority. That’s why one of OHCA’s five key tenets is “trust and transparency,” involving being committed to the principles of open government by providing consistent and accurate communication to members, providers, stakeholders and the public.
Because protecting Medicaid is a collaborative effort, prevention measures to root out fraud, waste and abuse touch every department in the agency. To make our work as transparent as possible, we’ve outlined current and historical actions taken to protect the program and the Oklahomans that depend on it.
What Is Fraud, Waste and Abuse?
Fraud is the intentional and criminal misuse of Medicaid funds.
Example: Intentionally billing for services that weren’t performed or billing for more services than delivered.
Waste and abuse are the unintentional and noncriminal misuse of Medicaid funds.
Example: Accidentally billing for a more expensive service or unknowingly billing for services that Medicaid doesn’t deem necessary.
For an action to be considered fraud, law enforcement must prove clear intent. Unintentional error, while still potentially misuse, is not considered fraud.
How to Report Suspected Fraud
Why It Matters
Every dollar matters. Protecting Medicaid means protecting access to care. Fraud, waste and abuse prevention help ensure resources are available for eligible members today and in the future.
Medicaid Spending
$12 Billion
Paid to providers in calendar year 2025
Medicaid Members
1.3 Million
Calendar year 2025
Medicaid Providers
57,724
Providers paid in calendar year 2025
Identified Overpayments
$4.5 Million
Calendar year 2025
Potential Fraud Cases
20 Cases
Referred to investigation in calendar year 2025
How We Prevent Fraud
OHCA’s Program Integrity division takes a zero-tolerance approach to fraud, waste and abuse. The team utilizes a defined vetting and escalation protocol where potential fraud is initially flagged through the provider revalidation process, targeted data analytics or direct observations from contracted entities (CEs). All incoming referrals, including those originating from CEs, are reviewed and validated by Program Integrity to ensure the necessary foundational evidence is present.
Medicaid Applications
- Citizenship confirmed through the SAVE program
- Income verified by Equifax
Provider Enrollment
- Background checks
- Site visits
- Credential verification
- Continuous monitoring
- Revalidation of high-risk providers
Staff Training and Compliance
- Employee education
- Provider education
- Compliance monitoring
Data Analytics
- Claims monitoring
- Pattern detection
- Predictive analytics
Audits and Reviews
- Pre-payment review
- Post-payment audits
- Record validation
Program Integrity Initiatives
JUNE 2026
CONTINUOUS MONITORING
OHCA will review providers on a continuous ad hoc basis when information is received confirming their designation according to one of the following criteria:
- Providers currently under payment suspension due to a credible allegation of fraud, waste or abuse.
- Providers with an unresolved Medicaid overpayment.
- Providers who have been excluded or disenrolled by Medicare or another state's Medicaid program within the last 10 years.
- Providers matching the HHS-OIG and SAM exclusion lists but not yet having been terminated.
Providers that fall into enhanced criteria go through a robust vetting process that utilizes a two-pronged system of monitoring fraud, waste and abuse. Enhanced state-defined criteria are as follows:
- High volume of beneficiary/provider complaints.
- Clinical quality concerns from internal or external sources.
- Aberrant billing patterns detected through data analysis.
JUNE 2026
HIGH-RISK PROVIDER REVALIDATION
OHCA will revalidate high-risk providers based on federal guidance and state-specific trends. Prioritization includes high-risk providers that are not Medicare-enrolled or enrolled in another state's Medicaid program, as well as providers that have had the longest period since their last revalidation. This totals fewer than 2.5% of OHCA providers and layers on top of the agency’s continuous monitoring system.
JUNE 2026
NEMT PROTOCOL REVIEW
OHCA is reviewing processes, procedures and guardrails for broker-contracted non-emergency medical transportation (NEMT) providers and will identify potential avenues to enhance oversight, analyze data and develop a permanent protocol.
JUNE 2026
PROVIDER EMPLOYEE IDENTIFICATION IN CLAIMS DATA
OHCA will require all home care and in-home service providers to enroll with a Medicaid Rendering Provider ID. For both fee-for-service and encounter claims data, providers must identify the specific employee rendering home and community-based waiver services. This requirement is designed to ensure accurate billing and eliminate claims discrepancies.
Success Stories & Results
To measure the effectiveness of the latest Program Integrity initiatives, OHCA will track performance metrics, including the following:
- Number of providers revalidated
- Number of revalidated providers disenrolled
- Disenrollment rate
- Number of disenrollments for specific reasons
The challenge: In early 2026, OHCA became aware of suspicious activity within SoonerSelect enrollment in which fraudulent applicants were attempting to take advantage of the reward programs offered by SoonerSelect plans. After the investigation team noticed unusual anomalies in the data that prompted a closer look, OHCA was able to confirm that several individuals were enrolled without their knowledge or consent.
The solution: After finding that these fraudulent enrollments had several common indicators, OHCA adjusted the application process.
The result: The enhanced security measures successfully block individuals trying to enroll in SoonerSelect using stolen or false identities.
The challenge: In 2025, an OHCA employee began tracking the rising costs of the ABA program. ABA, or applied behavior analysis, is widely used to support autistic children in developing communication, adaptive and behavioral skills.
In Oklahoma, Medicaid is the primary payer for ABA services. Utilization had increased sharply, with member counts rising from 820 per month in SFY 2023 to more than
1,900 per month in SFY 2026. This rising utilization increased ABA expenditures from $49.9 million in SFY 2023 to a projected $119.6 million in SFY 2026. Proposals to expand out-of-state provider participation and increase reimbursement rates would further accelerate this growth.
The solution: OHCA analyzed the regulatory structure, key issues and national trends in utilization management, and looked at comparisons in similar states. Comparison states illustrated a consistent pattern that helped direct OHCA’s next steps. This entailed strengthening medical necessity criteria, utilization management and oversight before expanding rates or removing geographic limits to help ensure sustainable, high-quality care.
The result: Consistency and accountability were strengthened, workforce development was supported, and group-based treatment reduced the per child cost. This meaningful oversight is helping to reduce fraud, waste and abuse.
Red Flags: What to Watch For
For Members
- Services on statements you didn’t receive
- Requests to share Medicaid (SoonerCare) ID cards
- Offers of cash or gifts for services
For Providers
- Altered records
- Suspicious billing requests
- Duplicate claims
For Employees
- Conflicts of interest
- Misuse of public funds
- Falsified documentation
Fraud-Related Resources
Identity Theft Resources
If you think someone has used your information, or if your information was lost, stolen or part of a data breach, report identity theft and get a recovery plan.
General Resources
Visit OHCA’s publications page and download the Medicaid Fraud Flyer to hang in your office. It provides phone numbers for individuals to call to report fraud, waste and abuse. The flyer is a free download, so you can print as many as you wish.
How to Report Suspected Fraud
Visit OHCA’s publications page and download the Medicaid Fraud Flyer to hang in your office. It provides phone numbers for individuals to call to report fraud, waste and abuse. The flyer is a free download, so you can print as many as you wish.
Before calling, please be ready to provide as much information as possible including the name of the doctor, hospital or other health care provider; the date of service; the amount of money that SoonerCare Medicaid approved and/or paid; and a description of the acts that you suspect involve fraud or abuse.
Medicaid Fraud Control Unit
Office of Attorney General
313 NE 21st Street
Oklahoma City, OK 73105
Oklahoma City: 405-521-3921
Tulsa: 918-581-2885
Provider Audits
Oklahoma Health Care Authority
4345 N. Lincoln Blvd.
Oklahoma City, OK 73105
405-522-7421
Before calling, please be ready to provide as much information as possible including the name of the SoonerCare Medicaid member, the member’s card number and a description of the acts that you suspect involve fraud or abuse.
State of Oklahoma Fraud Hotline
Oklahoma City: 800-784-5887
Member Audits
Oklahoma Health Care Authority
4345 N. Lincoln Blvd.
Oklahoma City, OK 73105
Statewide: 855-817-3728
Oklahoma City-405-522-5508
Email: member.investigation@okhca.org
All reporters can request to remain anonymous simply by requesting anonymity. Information is typically not released, but if anonymity is requested, their information is completely omitted from the file.
Office of Inspector General
U.S Department of Health and Human Services
Attn: Hotline
330 Independence Ave., SW
Washington, DC 20201
National hotline: 800-447-8477
TTY: 800-377-4950
If you suspect that your personal information was used without your knowledge or consent to apply for SoonerCare Medicaid coverage, please call the SoonerCare helpline at 800-987-7767 for assistance or fill out this fraud reporting form.
