Fraud, Waste, and Abuse

Understanding the terms:

Fraud: Intentional deception or misrepresentation to obtain the money or property of a health care benefit program (by means of false or fraudulent pretenses, representations, or promises).

  • Some examples of Fraud are: Knowingly billing for services not rendered, supplies not provided, or both, including falsifying records to show delivery of such items or billing for appointments that the patient did not attend.

Waste: The over-utilization of services or other practices that result in unnecessary costs.

  • Some examples of Waste are: Making excessive office visits or ordering excessive laboratory testing.

Abuse: Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments.

  • Some examples of Abuse are: Billing for services that were not medically necessary; charging excessively for services or supplies; and misusing codes on a claim, such as up-coding or unbundling services.

What can you do to help prevent, report, and stop Fraud, Waste, and Abuse?

To report potential fraud, waste and abuse in the Medicare program, please use one of the following applicable channels:

Medicare Fraud Hotline of the HHS office of Inspector General:

  • Phone: 1-800-447-8477 (TTY: 1-800-377-4950) Phone lines are open 24 hours a day, 7 days a week.
  • Fax: 1-800-223-8164
  • EmailHHSTips@oig.hhs.gov
  • National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC): 1-877-7SafeRx (1-877-772-3379)

http://medicare.gov/fraud

 

Fraud:

Intentional deception or misrepresentation to obtain the money or property of a health care benefit program (by means of false or fraudulent pretenses, representations, or promises).

  • Some examples of consumer health care fraud:
    • filing claims for services or medications not received
    • forging or altering bills or receipts
    • using someone else's coverage or insurance card

  • Some examples of provider health care fraud:
    • billing for services not actually performed
    • falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
    • upcoding – billing for a more costly service than the one actually performed

  • Some examples of non-compliance:
    • theft or unauthorized removal of company/business documents from the premises
    • falsifying or tampering with company documents or records
    • violations of Health Net's Code of Conduct
    • insubordination, dishonesty, gross carelessness/negligence of duties

Waste: 

The over-utilization of services or other practices that result in unnecessary costs.

  • Some examples of Waste are: 
    • making excessive office visits or ordering excessive laboratory testing

Abuse: 

Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments.

  • Some examples of Abuse are: 
    • billing for services that were not medically necessary 
    • charging excessively for services or supplies 
    • misusing codes on a claim, such as up-coding or unbundling services

To report potential fraud, waste and abuse in the Medicare program, please use one of the following applicable channels:

  • Health Net's Fraud hotline and Integrity hotline are available 24/7, and callers may choose to remain anonymous.
    • Health Net Fraud Hotline: 1-866-685-8664
    • Health Net Integrity Hotline: 1-888-866-1366
    • TTY: 711
    • Online: Help fight Medicare Fraud
  • Medicare Fraud Hotline of the HHS office of Inspector General:
    • Phone: 1-800-447-8477 (TTY: 1-800-377-4950). Phone lines are open 24 hours a day, 7 days a week.
    • Fax: 1-800-223-8164
    • Email: HHSTips@oig.hhs.gov
    • National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC): 1-877-7SafeRx (1-877-772-3379)

http://medicare.gov/fraud

What to include in your report:

  1. Unless you choose to remain anonymous, please provide your name, telephone number, address, and email address. If you are submitting your report anonymously, please take care to withhold personally identifiable information.
  2. Explain the nature, scope and time frame of the activity in question.
  3. Explain how you are aware of the alleged activity.
  4. Specify if you know of any potential witnesses to the activity.
  5. Provide any documents or other physical evidence in your possession.
  • Broward County, Florida
  • Harris County, Texas
  • Kings County, New York
  • Los Angeles County, California
  • Miami-Dade County, Florida

*As of July 1, 2011, Centers for Medicare & Medicaid Services identified these five counties as most at risk for high incidences of fraud, waste and abuse.