RALEIGH – Attorney General Jeff Jackson today appeared in front of the General Assembly’s House Select Committee on Oversight and Reform to highlight his Medicaid Investigations Division’s efforts to find, investigate, and prosecute Medicaid provider fraud.
“Our Medicaid Investigations Division is one of the best in the country and is pioneering new ways to find Medicaid fraud and prosecute criminals,” said Attorney General Jeff Jackson. “We’re going to keep at this work to protect taxpayer dollars for taxpayers’ health care.”
The Medicaid Investigations Division (MID) is North Carolina’s Medicaid Fraud Control Unit, the federal unit required to ensure taxpayer dollars in the Medicaid program go to fund patient care, not fraud. Under federal law, MID can investigate and prosecute Medicaid provider fraud and patient abuse, not recipient fraud.
CLIP 1: “Here is what becomes an investigation: anything that has good evidence of fraud. Whether it is one dollar or a million dollars, there is no acceptable level of fraud. None. I have told my team that even though we are big game hunters – we take out a lot of big game – if we have good evidence that there is one dollar of fraud, we’re going to go after it. To your question, how can you know that we really do this job well? It is because we are eighth in the nation for recovery over the last six years. We are fourth in the nation in recovery per dollar of funding we have received. That is the true metric that determines how we are doing relative to our peers.”
CLIP 2: “In 2017, we became the third state to request a federal waiver from HHS (federal HHS) to give us access to backend billing data. They did that. We then asked investigators to volunteer for duty on top of their full-time job to come together and form basically an ad-hoc data mining team. They did that. It has produced 68 investigations. I can’t remember how many convictions, I want to say eight or nine, and tens of millions of dollars recovered – more money recovered from this ad-hoc team than has been paid to fund all of MID for the last decade. So clearly this is fruitful. Now add to that AI, which was not a tool in 2017, 2018, 2019, but is a tool now. Not general AI, but specific software that exists to look for, specifically, upcoding and phantom billing. We would be fools not to take advantage of this, and our federal partners are giving us data. They want us to move in this direction. Other states are coming to us asking to be trained in this.
CLIP 3: “Attorney General Jackson, I can tell you, one, I am rooting for you…You’re still shaping your agency, and I think we’re all depending on you to do the big game hunting that all of us as North Carolinians are looking for. So, I thank you for being here, and I look forward to you getting results.”
As Attorney General Jackson said during the hearing, MID’s staff are nationally-recognized leaders in the National Association of Medicaid Fraud Control Units.
Some highlights of MID’s prosecution efforts:
- MID has recovered more than $1.2 billion in restitution and civil damages since it was created.
- Between 2019 and 2025, it recovered more than $296 million, the eighth highest among Medicaid Fraud Control Units in the United States.
- For every dollar of federal funding received in that same time, MID recovered $6.28 for Medicaid, the fourth highest recovery rate in the nation and close to double the national average of $3.39.
During the hearing, Attorney General Jackson also highlighted MID’s data mining to proactively uncover Medicaid provider fraud instead of relying solely on referrals. By data mining, MID reviews federal data from Medicaid claims to identify irregularities in billing that might indicate fraud. MID’s data mining led to the division’s largest criminal conviction this year, a $12.7 million conviction against five defendants who were sentenced to between two and six years in prison each. North Carolina was one of the first states to get permission from the U.S. Department of Health and Human Services to investigate potential fraud through data mining Medicaid claims.
Since data mining efforts began in 2017, they have led to 68 investigations, 6 criminal convictions with more than $27 million in ordered restitution, and 18 civil False Claims Act settlements with more than $10 million in ordered restitution and penalties.
Some highlights of Medicaid convictions and settlements Attorney General Jackson has won since taking office:
- In March, Kimberly Sims was sentenced in a scheme that defrauded the North Carolina Medicaid program of over $12.7 million. The case, which involved five defendants, was an example of MID’s data mining efforts. In total, the defendants were ordered to repay more than $2.5 million to the IRS and more than $15 million to Medicaid.
- In January, Kathy Briggs — co-owner of Neveah & Company, which was operating as Restorative Medical — was sentenced to prison and ordered to pay more than $2.4 million in restitution for her role in in a scheme to submit fraudulent claims for incontinence products to Medicaid.
- Earlier that month, Bethany Medical Center, P.A., and its founder, Lenin Peters, M.D., paid more than $8.8 million following accusations that they knowingly billed Medicare, Medicaid, and TRICARE for medically unnecessary urine drug tests.
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