Fraud, waste and abuse prevention
At Healthy Blue, we have a zero-tolerance policy on waste, fraud and abuse (WFA), and everyone is responsible to make a difference. Our mission is to protect the overall integrity of the healthcare system, as well as to protect our members, providers, business partners and stakeholders by administering a comprehensive and effective anti-fraud plan to prevent, detect, investigate and resolve allegations of potential WFA.
What do we mean by waste, fraud and abuse?
An attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, but the outcome of a billing error caused unnecessary costs to the involved companies. Waste includes overutilization of services not caused by criminally negligent actions. Waste also involves the misuse of resources.
A false representation of a matter of fact — whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed — that deceives and is intended to deceive another so that the individual will act upon his or her legal injury.
Provider practices that are inconsistent with generally accepted business or medical practices and result in an unnecessary cost to the Medicaid or Medicare program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for healthcare; or recipient practices that result in unnecessary cost to the Medicaid or Medicare program.
Other terms defined
Services not rendered
Billing for goods and/or services that were never delivered or provided.
Not medically necessary
Performing inappropriate or unnecessary medical procedures in order to increase payment.
Using multiple billing codes instead of one billing code for a drug panel test in order to increase payment.
Billing for a higher level of service than was actually provided.
Forging a physician’s signature to obtain pharmaceutical goods.
Charging more than once for the same goods or services.
Not providing adequate medical care to increase profits.
Enrolling a beneficiary into a health plan without that person’s knowledge.
Theft of services
Utilizing someone else’s insurance card to receive services; either through stealing the card or having it provided by the true card holder.
Overpayment defined in accordance with s. 409.913, F.S., includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.
Waste, fraud and abuse response
Tell us of suspected waste, fraud or abuse of services paid for by Healthy Blue. www.fighthealthcarefraud.com
Reporting waste, fraud and abuse
If you suspect a provider (provider group, hospital, doctor, dentist, counselor, medical supply company, etc.) or any member (a person who receives benefits) has committed waste, fraud or abuse, you are encouraged to report it. No individual who reports violations or suspected fraud and abuse will be retaliated against for doing so. The name of the person reporting the incident and their callback number will be kept in strict confidence by investigators.
You can report your concerns by:
Special Investigations Unit fraud hotline