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Fraud, Waste, and Abuse

Learn how you can help limit and identify fraud, waste, and abuse.

Medicare Program Fraud, Waste, and Abuse

Fraud, waste, and abuse (FWA) are growing problems within healthcare programs in the United States, including within the Medicare program.
SelectHealth is taking actions to detect, reduce, and prevent FWA. SelectHealth has a designated Special Investigations Unit (SIU)
that investigates potential FWA including any incidences reported or detected by SelectHealth staff, healthcare providers, or our members,
among other sources.

 

What Are Fraud, Waste, and Abuse?

The following definitions for FWA are from the Centers for Medicare and Medicaid Services (CMS), who regulate and oversee health plans
like SelectHealth Advantage within the Medicare Advantage program.

Fraud: An intentional deception or misrepresentation that an individual or entity makes knowing that the misrepresentation could result
in obtaining unauthorized benefits or money under the control of any healthcare benefit program.

Examples of fraud may include:

  • A healthcare provider performing medically unnecessary services solely for the purpose of generating coverage payments.
  • Presenting a Medicare card that belongs to someone else to obtain medical care, supplies or equipment, or prescriptions.
  • Prescriptions that look to have been altered or forged.

 

Waste: An over utilization or misuse of services or other practices that results in unnecessary costs to the Medicare program but are generally
not considered to be criminal actions.

Examples of waste may include:

  • Use of emergency room services for nonemergencies
  • Unintentional incorrect billing for services

 

Abuse: includes any actions that may—directly or indirectly—result in unnecessary costs to the Medicare program, improper payments for
services, or services that are medically unnecessary. Abuse differs from fraud only based on specific facts and circumstances including
intent.

Examples of abuse may include:

  • A healthcare provider billing for services or equipment not received
  • Attempting to fill one prescription at different pharmacies on the same day

 

Be Part Of The Solution

Reporting is essential for the prevention, detection, and correction of fraud, waste, and abuse. To report potential fraud, waste, and abuse,
please call the Compliance Hotline at 800-442-4845. Anonymous reporting and interpretation services are available. To speak to
someone or ask questions about plan benefits or coverage, please call Member Services at 855-442-9900 (TTY: 711).

More information is available by requesting the guide titled “Protecting Medicare and You from Fraud” by calling 1-800-Medicare
(1-800-633-4227). TTY users, please call 877-486-2048. A customer service representative can answer your questions 24 hours a day,
7 days a week.