Preventing Healthcare Fraud, Waste, & Abuse

Fraud is generally defined as the intentional misuse of information in an effort to receive an unauthorized benefit. Waste involves using, consuming, or spending thoughtlessly or carelessly. Abuse involves improperly using program resources for personal gain.

Here are some examples of fraud, waste, and abuse:

• A provider billing for medical services or items that were not ordered or provided
• A provider providing services or items that a person does not need or are not medically necessary
• A provider billing for services that are more complex than what was actually performed, resulting in higher costs
• A patient who may or may not be ill seeing doctor after doctor in order to obtain multiple prescriptions for painkillers
• A member receiving suspicious phone calls asking for personal health information