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Fraud, waste and abuse 

Aetna Better Health® of West Virginia is committed to stopping fraud, waste and abuse. We look to our members and providers to help. So, if you see fraud, waste or abuse, report it right away.

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

This 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 

This  includes: 

 

  • 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?

Who can you call?

To prevent, report or stop fraud, waste and abuse, you can call:

 

You can also fill out our fraud, waste and abuse form.

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.