Fraud, Waste, and Abuse Prevention
Senior Whole Health seeks to uphold the highest ethical standards for the provision of health care benefits and services to its members and supports the efforts of federal and state authorities in their enforcement of prohibitions of fraudulent practices by providers or other entities dealing with the provision of health care services.
“Abuse” means practices that are inconsistent with sound fiscal, business or medical practices that result in an unnecessary cost to the Medicaid/Medicare programs or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid/Medicare programs. (42 CFR 455.2 and as further defined in Welf. & Inst. Code Section 14043.1 (a).)
"Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. (42 CFR 455.2 W. & I. Code Section14043.1(i).)
“Waste” is health care spending that can be eliminated without reducing the quality of care.
Federal False Claims Act, 31 USC Section 3279
The False Claims Act is a federal statute that covers fraud involving any federally funded contract or program, including the Medicare and Medicaid programs. The Act establishes liability for any person who knowingly presents or causes to be presented a false or fraudulent claim to the U.S. government for payment. The term "knowing" is defined to mean that a person with respect to information:
- Has actual knowledge of falsity of information in the claim;
- Acts in deliberate ignorance of the truth or falsity of the information in a claim; or
- Acts in reckless disregard of the truth or falsity of the information in a claim.
The Act does not require proof of a specific intent to defraud the U.S. government. Instead, health care providers can be prosecuted for a wide variety of conduct that leads to the submission of fraudulent claims to the government, such as knowingly making false statements, falsifying records, double-billing for items or services, submitting bills for services never performed or items never furnished or otherwise causing a false claim to be submitted.
Health care fraud is:
Health care fraud includes but is not limited to the making of intentional false statements, misrepresentations or deliberate omissions of material facts from any record, bill, claim or any other form for the purpose of obtaining payment, compensation or reimbursement for health care services.
By a Member
By a Provider
Using someone else’s insurance card.
Falsifying codes orrecords or altering claims.
Forging a prescription.
Billing for services not rendered or goods not provided.
Knowingly enrolling someone not eligible for coverage under their policy or group coverage.
Billing separately for services that should be a single service.
Providing misleading information on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits.
Billing for services not medically necessary.
Alerting the billed amount for services. Altering the service date.
Overutilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedure for diagnosis.
Other Provider Crimes
- Knowingly and willfully solicits or receives payment of kickbacks or bribes in exchange for the referral of Medicare or Medicaid patients. (Anti-Kickback Statute)
- Knowingly and willfully referring Medicare or Medicaid patients to health care facilities in which or with which the provider has a financial relationship. (The Stark Law).
- Balance billing - asking the patient to pay the difference between the discounted fees, negotiated fees and the provider's usual and customary fees.
Preventing Fraud, Waste, and Abuse
Healthcare fraud, waste, and abuse is on the rise. Senior Whole Health and state and federal agencies are working together to help prevent fraud, waste, and abuse. Here are a few helpful tips on how you can help prevent healthcare fraud, waste, and abuse:
- Do not give your Senior Whole Health ID Card or number to anyone except your provider, clinic, hospital or other healthcare provider.
- Do not let anyone borrow your Senior Whole Health ID Card.
- Never lend your social security card to anyone.
- When you get a prescription make sure the number of the pills in the bottle matches the number on the label.
- Never change or add information on a prescription.
- If your Senior Whole Health ID Card is lost or stolen, report it to Senior Whole Health immediately.
Reporting Fraud, Waste, and Abuse
You may report suspected cases of fraud, waste, and abuse to Senior Whole Health's Compliance Officer. You have the right to have your concerns reported anonymously to Senior Whole Health, and/or United States Office of Inspector General. When reporting an issue, please provide as much information as possible. The more information provided the better the chance the situation will be successfully reviewed and resolved. Remember to include the following information when reporting suspected fraud or abuse:
- Nature of complaint
- The names of individuals and/or entity involved in suspected fraud and/or abuse including address, phone number, Medicaid ID number and any other identifying information.
You may report fraud, waste, and abuse to Senior Whole Health through one of the following:
Call the Toll-Free number of the Senior Whole Health Anti-Fraud Line:
(866) 606-3889 TTY/TTD:711
24 hours a day, 7 days a week
Report an issue online through a confidential and secure site, visit:
You may report fraud, waste, and abuse to the United States Health and Human Services Office of Inspector General at:
Office of the Inspector General
P.O. Box 23489
Washington D.C., 20026
HHS TIPS Fraud Hotline: (800) HHS-TIPS
Additional health care compliance and anti-fraud information may be accessed by visiting the following website:
Centers for Medicare & Medicaid Services
(Information Relative to the Medicare Program and National Health Care Laws)
90 7th Street, Suite 5-300 (5W)
San Francisco, CA 94103-6707
For those who do not have access to computers in your home, Internet access is available at your local public library.
*Materials are also available in printed formats.