Waste, fraud & abuse prevention

Our mission

 

Our mission is to protect the overall integrity of the healthcare system, as well as to protect our members, providers, business partners and stakeholders by administering a comprehensive and effective anti-fraud plan to prevent, detect, investigate and resolve allegations of potential waste, fraud and abuse (WFA).

What do we mean by waste, fraud and abuse? 

 

 

Waste

 

An attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, but the outcome of a billing error caused unnecessary costs to the involved companies. Waste includes overutilization of services not caused by criminally negligent actions. Waste also involves the misuse of resources.

 

 

Fraud

 

A false representation of a matter of fact — whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed — that deceives and is intended to deceive another so that the individual will act upon his or her legal injury.

 

 

Abuse

 

Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for healthcare; or recipient practices that result in unnecessary cost to the Medicaid program.

Other terms defined

 

Familiarize yourself with additional terms that are associated with WFA.

 

Services not rendered - Billing for goods and/or services that were never delivered or provided.

 

Not medically necessary - Performing inappropriate or unnecessary medical procedures in order to increase payment.

 

Unbundling - Using multiple billing codes instead of one billing code for a drug panel test in order to increase payment.

 

Up-coding - Billing for a higher level of service than was actually provided.

 

Misrepresentation - Forging a physician's signature to obtain pharmaceutical goods.

 

Double billing - Charging more than once for the same goods or services.

 

Underutilization - Not providing adequate medical care to increase profits.

 

Enrollment fraud - Enrolling a beneficiary into a health plan without that person's knowledge.

 

Theft of services - Utilizing someone else's insurance card to receive services; either through stealing the card or having it provided by the true card holder.

 

Overpayment - Overpayment includes any amount that is not authorized to be paid by the Medicaid program, whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.

Reporting healthcare WFA

 

If you have a reason to believe waste, fraud or abuse (WFA) may have been committed, please contact us immediately and together we can make a difference. You can contact us via the following options:

• Complete the Fraud, Waste and Abuse form on fighthealthcarefraud.com education site; at the top of the page, select the button labeled "Report it" to complete the Report Waste, Fraud and Abuse form
• Calling Health Care Networks if you are a contracted provider
• Calling Customer Service
• Calling our Special Investigative Unit (SIU) fraud referral hotline: 866-847-8247