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What are fraud, waste and abuse?
Fraud happens when someone lies to get money or services.
Waste happens when someone uses benefits or services they don’t need.
Abuse happens when someone takes money for services when they aren’t legally entitled to payment.
Provider fraud, waste and abuse includes:
Falsifying medical records
Prescribing more medication than is medically necessary
Giving more health care services than medically necessary
Billing for services that were not rendered
Billing for items not provided
Billing for professional services when a medical professional didn’t perform the service
Committing verbal, physical, mental or sexual abuse
Member fraud, waste and abuse includes:
Lending, selling or giving a health plan ID card to someone else
Getting similar treatments from different doctors
Getting medicines that aren’t necessary
Going to an emergency room if you know it’s not an emergency
Using someone else’s Social Security number or member ID number
Receiving money or gifts in exchange for having medical services