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What are fraud, waste and abuse?
Fraud, waste and abuse are dishonest actions by providers or members.
- Fraud happens when someone lies to get money or services.
- Waste happens when someone gets benefits or services (for themselves or others) that they aren’t entitled to or don’t need.
- Abuse happens when someone takes money for services when they haven’t earned payment.
Provider fraud, waste and abuse
Provider fraud, waste and abuse includes:
Falsifying medical records
Prescribing more medication than is medically necessary
Billing for professional services when a medical professional didn’t perform the service
Giving services that members don’t need
Billing for services or items they didn’t give
Abusing members verbally, physically, mentally or sexually
Member fraud, waste and abuse
Member fraud, waste and abuse includes:
Lending, selling or giving a health plan ID card to someone else
Getting medicines or services they don’t need
Forging or changing prescriptions from providers
Getting similar treatments from different doctors
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