What is Fraud Waste and Abuse?

FRAUD

An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. 

Overutilization of services, or other practices that result in unnecessary costs.  Waste is generally not caused by criminally negligent actions but rather misuse of resources.

WASTE

ABUSE

ABUSE – An individual’s activities that are inconsistent with sound fiscal, business, or medical practices that result in unnecessary cost, reimbursement for services that are not medically necessary or fail to meet professionally recognized standards.

EXAMPLES OF FRAUD, WASTE AND ABUSE:

  • Unnecessary treatments

  • Using someone else’s insurance card

  • Altering or forging a prescription

  • 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 rendered and/or goods not provided

  • Knowingly enrolling someone not eligible for coverage under their policy or coverage

  • Double billing

  • Misrepresentation of services

  • Billing separately for services that should be a single service

  • Billing for services not medically necessary

  • False coding, altering records, or claims

  • Altering medical record documentation

  • Limiting access to needed services

  • Soliciting, offering or receiving a kickback, bribe or rebate

  • Misrepresentation of medical conditions

PLEASE NOTE: Per 45 CFR Part 160 and Subparts A and E of Part 164, all HIPAA-covered entities and business associates must comply with the Privacy Rule requirements applicable to all forms of protected health information (PHI) including oral, paper, and electronic. The Privacy Rule applies to any information that may reasonably allow someone to identify an individual (e.g. Name, Address, Birthdates and dates of service, Phone numbers, E-mail addresses, Social security numbers, Health insurance plan information and Photos).

How to Report

Report to Great Rivers

You many report suspected fraud, waste, and abuse anonymously to the Great Rivers Compliance Officer:

 

Phone:
800.272.8917

Email:
Comply_WFA@grbhaso.org

 

Mail:
Great Rivers BH-ASO

PO Box 210
Chehalis, WA 98532

 

Other ways to report

Washington State Office of the Attorney General Medicaid Fraud Control Unit

 

Phone:
360.586.8888

Fax:
360.586.8877

Email:
MFCUreferrals@atg.wa.gov

 

Mail:
Office of the Attorney General
Medicaid Fraud Control Unit

PO Box 40114
Olympia, WA 98504

 

OIG National Fraud Hotline

Phone:
1.800.HHS.TIPS (1.800.447.8477)

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