How Maine DHHS Oversees Public Funds and Responds to Allegations of Fraud
The Maine Department of Health and Human Services (DHHS) provides essential health and social services to Maine residents while safeguarding the public resources entrusted to our care. Every dollar we manage represents a commitment to ensure funds are used lawfully, effectively, and in direct support of the programs and people they are intended to serve.
Given recent public interest in the handling of fraud allegations within publicly funded programs, it is important to share information about the actions the Department takes in service to its critical role in oversight, compliance, and accountability.
How DHHS Oversees Programs and Protects Public Funds
Maine DHHS operates under a framework of continuous audit, claims review, and compliance monitoring grounded in state and federal law. These processes are designed to identify billing errors, detect noncompliance, address documentation gaps, and ensure public funds are used appropriately.
When issues are identified, the Department acts through mandatory corrective action plans, recovery of overpayments, or referral to appropriate law enforcement entities, depending on the facts and the law.
The Department's Primary Oversight Units
Three units within the Department play a central role in identifying and responding to issues that may rise to the level of a credible allegation of fraud. While these are not the only oversight mechanisms within DHHS, they represent the Department's primary tools for ensuring compliance and integrity:
- DHHS Division of Audit manages compliance reviews of expenditures across Department contracts and MaineCare, including cost-settled payments.
- Fraud Investigation and Recovery Unit within the Office for Family Independence (OFI) investigates and acts primarily on allegations and instances of fraud by recipients of benefits.
- MaineCare Program Integrity Unit within the Office of MaineCare Services (OMS) conducts surveillance and review of provider billing and practices and, when appropriate, refers matters to the Healthcare Crimes Unit within the Office of the Attorney General, Maine's Medicaid Fraud Control Unit. Referrals occur when program reviews identify noncompliance that meets the legal threshold of a credible allegation of fraud.
Together, these units illustrate the structured, disciplined processes the Department follows to identify and address fraud, overpayments, and noncompliance -- and to refer matters for criminal investigation when legally required.
How to Report Suspected Fraud
Anyone who suspects fraud, attempted fraud, or misuse of funds administered by Maine DHHS can report it directly to the Department.
DHHS maintains a secure, online fraud reporting form that can be used by members of the public, providers, or employees to submit concerns. Reports can be made about suspected fraud or attempted fraud involving programs or funds administered by the Department.
Reports can be submitted here.
All reports are reviewed and assessed and, when appropriate, referred to the Office of the Attorney General or other law enforcement agencies.
What Happens When Fraud Is Suspected
When the Department encounters a credible allegation of fraud, it is required by law to refer that matter to the Office of the Attorney General or appropriate law enforcement agencies. DHHS does not conduct criminal investigations.
This division of responsibility is intentional:
- DHHS identifies, documents, acts within its authority, and refers
- Law enforcement investigates and prosecutes
- Courts determine culpability
This separation protects due process, preserves investigative integrity, and ensures accountability is pursued through independent and appropriate channels.
Why Payment Suspensions Occur
State and Federal law also require the Department to take specific actions when a credible allegation of fraud is identified.
Under Federal regulation 42 C.F.R. § 455.23, Maine law 22 M.R.S. § 1714-E, and MaineCare rules, the Department must impose a payment suspension unless "good cause" criteria are met to delay that action.
Those exceptions are narrow and purposeful, such as when law enforcement requests a delay to avoid compromising an active investigation or when patient access to essential services could be harmed.
Taken together, this means the Department's work in this area is not driven by discretion or informal judgment. It is grounded in statutory requirements, documented processes, independent review, and external enforcement.
Why This Structure Matters
This system is not permissive. It is one of rigorous checks and balances designed to ensure due process. These processes take time to allow for careful review, appropriate documentation, and coordination with law enforcement when needed, so that cases can be built properly and essential services are not disrupted for the people who rely on them.
This structure is intended to protect taxpayers, preserve program integrity, and ensure misuse of public funds is addressed, while also safeguarding due process and access to essential services for the people of Maine.
Maintaining Public Trust
The Department takes allegations of fraud very seriously. That commitment is reflected in rigorous oversight, transparency, and coordination with law enforcement and providers to ensure these systems remain worthy of public trust.
As recently experienced, public awareness of fraud typically follows the identification of concerns and the initiation of formal enforcement or investigative processes, which is evidence that these oversight systems are functioning as intended.
Ultimately, trust is not built through rhetoric. It is built through consistent, lawful, and disciplined action. That is the standard the Department holds itself to, and it is the standard the people of Maine deserve.