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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
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
Lending, selling or giving a health plan ID card to someone else
Getting medicines or services you 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
Who can you call?
How to help us reduce fraud:
- Be careful where you share your health care info. This includes info like your member ID number. Watch out for “free” medical services, especially if you’re asked to share personal health care info.
- Look out for letters we send to you in the mail. Your providers send us bills to pay. These are bills for your doctor visits and other services and supplies. We may send you letters that tell you how we paid for those bills and ask you questions to make sure a bill is right. If you get one of these letters, just fill in the answers and mail it back to us as soon as you can.
- Know your plan and benefits info. This incldes things like what types of treatments, drugs and services are covered.