Fraud, Waste and Abuse: How Do I Identify and Report It?
Fraud, waste and abuse – what they are and how to stop them.
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What is fraud?
Fraud means intentionally deceiving or misrepresenting information knowing it could result in an unapproved benefit to yourself or another. Fraud can be:
- Using someone else’s Social Security number to qualify for government assistance.
- A doctor intentionally billing for services they didn’t give.
If you commit fraud, you may lose your Medicaid coverage.
What is waste?
Waste is the overuse of services or careless practices that result in throwing away or the spending of health care or government resources in an unwise and wrong manner. Examples of waste are:
- Prescribing more medication than medically necessary.
- Providing more health care services than medically necessary.
What is abuse?
Abuse is an action resulting in unnecessary costs to government programs such as Medicaid. Abuse may also result in improper benefits to a member or improper payment to doctors. Examples of abuse include:
- Requesting and obtaining medications or medical equipment for someone else.
- Excessive use of the emergency room (ER) for nonemergency or routine care.
How to report fraud, waste and abuse
If you believe a client (a person who gets benefits) or a provider (a doctor, dentist, counselor, etc.) has committed fraud, waste or abuse, you have a responsibility and a right to report it. You also have the right to remain anonymous when reporting fraud, waste or abuse. To report fraud, waste or abuse, get as many details as you can. You may report providers or clients to your health plan by:
- Calling our Customer Care Center (CCC) at 1-866-781-5094.
- Calling the BlueChoice HealthPlan Medicaid Fraud Hotline at 1-877-725-2702 or email email@example.com.
- Faxing the BlueChoice HealthPlan Medicaid Fraud Referral Form to 1-866-494-8279.
- Writing to:
BlueChoice HealthPlan Medicaid
P.O. Box 66407
Virginia Beach, VA 23466
- Calling the South Carolina Medicaid Fraud Hotline at 1-888-364-3224 or email firstname.lastname@example.org.
When you report a provider (a doctor, dentist, counselor, etc.), give these details:
- Name, address and phone number of the provider
- Name and address of the place (hospital, nursing home, home health agency, etc.)
- Medicaid number of the provider and place if you know it
- Type of provider (doctor, physical therapist, pharmacist, etc.)
- Names and phone numbers of other people who may be able to give us some of these details
- Dates of events
- A brief statement of what happened
When you report a client (a person who gets benefits), give these details:
- The person’s name
- The person’s date of birth and Social Security number if you know it
- The city where the person lives
- Exact details about the waste, abuse or fraud
Why should I care about fraud, waste, and abuse?
Everyone is hurt by fraud, waste and abuse. Millions of dollars are paid to those not entitled to get services or cash. That money could be spent to provide more care to people in need or more benefits to you. Do you know someone getting care they aren’t supposed to get? Do you suspect a doctor or lab of billing too much or billing for services not provided? If yes, please use our Fraud Hotline or call the CCC.
Fraud, Waste and Abuse for Providers