Fraude, malgasto y abuso
You Can Make a Difference. Report Suspected Fraud.
Did You Know?
- Healthcare fraud is contributing to the rising cost of health insurance.
- Healthcare fraud reduces the amount of funds available to pay honest providers.
- Healthcare fraud increases premiums to employers and members.
- We will investigate allegations of fraud, waste and abuse – and reports of non-compliance on any level.
- Our Special Investigations Unit is available as a resource to our employees, members and providers, as well as to our delegates – first tier, downstream and related entities.
- See below for examples of fraud and more.
Fraud:
Intentional deception or misrepresentation to obtain the money or property of a healthcare benefit program (by means of false or fraudulent pretenses, representations or promises).
Some examples of consumer healthcare fraud:
- Filing claims for services or medications not received
- Forging or altering bills or receipts
- Using someone else's coverage or insurance card
Some examples of provider healthcare fraud:
- Billing for services not actually performed
- Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
- Upcoding – billing for a more costly service than the one actually performed
Some examples of non-compliance:
- Theft or unauthorized removal of company/business documents from the premises
- Falsifying or tampering with company documents or records
- Violations of our company's Code of Conduct
- Insubordination, dishonesty, gross carelessness/negligence of duties
Waste:
The over-utilization of services or other practices that result in unnecessary costs.
Some examples of waste are:
- Making excessive office visits or ordering excessive laboratory testing
Abuse:
Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments.
Some examples of abuse are:
- Billing for services that were not medically necessary
- Charging excessively for services or supplies
- Misusing codes on a claim, such as up-coding or unbundling services
Report Fraud, Waste and Abuse
To report potential fraud, waste and abuse in the Medicare program, please use one of the following applicable channels:
- Wellcare Prime by Absolute Total Care: 1-855-735-4398; (TTY: 711). Hours are from 8 a.m. to 8 p.m., Monday through Friday. After hours, on weekends and on federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.
- South Carolina Department of Health and Human Services (SCDHHS) Program Integrity: 1-888-364-3224; (TTY: 711)
- Medicaid Fraud Control Unit: 1-888-662-4328; (TTY: 711)
- Medicare or Medicaid Fraud Hotline: 1-800-447-8477; (TTY: 711)
- South Carolina Office of Inspector General: 1-855-723-7283 (1-855-SC-Fraud); (TTY: 711)
- Online: Medicare.gov.
What to include in your report:
- Unless you choose to remain anonymous, please provide your name, telephone number, address and email address. If you are submitting your report anonymously, please take care to withhold personally identifiable information.
- Explain the nature, scope and time frame of the activity in question.
- Explain how you are aware of the alleged activity.
- Specify if you know of any potential witnesses to the activity.
- Provide any documents or other physical evidence in your possession.
All information will be kept private. Eliminating fraud, waste and abuse will provide more time and money for your healthcare needs.
The following links explain common fraud schemes that could impact members.
- Genetic Testing (PDF)
- Charging for Prescriptions (PDF)
- Open Enrollment Identity Theft (PDF)
- Before You Change Coverage (PDF)
- Email Scams (PDF)
- Prescription Drug Abuse and Misuse (PDF)
- Discount Prescription Drug Card Scams (PDF)
- Telemarketing Scams (PDF)
- Risks Associated with Online Pharmacies (PDF)
- Home Health Fraud (PDF)
- Medical Transportation Fraud (PDF)
- Health Insurance Marketplace Fraud (PDF)
- Questioning Free Medical Supplies - English (PDF)
- Questioning Free Medical Supplies - Spanish (PDF)
- Services Not Provided - English (PDF)
- Services Not Provided - Spanish (PDF)
- Identify Theft Prevention Tips - English (PDF)
- Identify Theft Prevention Tips - Spanish (PDF)
- Other Fraud Considerations - English (PDF)
- Other Fraud Considerations - Spanish (PDF)
The following links address other important matters.
- Miami, Tampa and Orlando, Florida
- Los Angeles, California
- Detroit, Michigan
- Dallas, San Antonio and Houston, Texas
- Brooklyn, New York
- Baton Rouge and New Orleans, Louisiana
- Chicago, Illinois
- Ft. Mitchell, Kentucky
- Nashville, Tennessee
- Newark, New Jersey/Philadelphia, Pennsylvania
- Washington, D.C.
*As of Fiscal Year 2019, the Department of Health and Human Service Office of Inspector General and the Department of Justice identified these U.S. cities/regions as most at risk for high incidences of fraud, waste and abuse.