Report Fraud, Waste, and Abuse

Health care fraud is a crime that has a big impact on the health care system, and you play a vital role in stopping fraud, waste, and abuse.

Unfortunately, there may be times when you see fraud, waste, and abuse relating to health care services.

How to report fraud, waste, and abuse

You can report fraud, waste, and abuse by following the instructions below. Please include as much detail as you can. You are not required to provide your personal information.

To report member or provider fraud, waste, and abuse:

Phone: Fraud Tip Hotline at 1-866-833-9718, Monday through Friday, from 7 a.m. to 6 p.m.

Online: U.S. Department of Health and Human Services at the Office of Inspector General

What are fraud, waste, and abuse?

Fraud is a false statement from someone who knows that the statement is false.

  • Example: Sam's doctor provides a service to Sam that the doctor knows won't be covered. Sam's doctor says that he provided a covered service instead.

Waste is when someone uses a service more than they need to.

  • Example: Rachel asks two different doctors to give her the same medicine. She now has more medicine than she needs.

Abuse may not be intentional and is when actions lead to extra health care costs or losses to the health care system.

  • Example: Jonathan's doctor sends him to get an X-ray when he does not need one.

Examples of provider fraud and abuse

  • Billing or charging you for services that First Choice Next covers
  • Offering you gifts or money to get treatment or services you do not need
  • Offering you free services, equipment, or supplies in exchange for using your First Choice Next member number
  • Giving you treatment or services you do not need
  • Physical, mental, or sexual abuse by medical staff

Examples of member fraud and abuse

  • Members selling or lending their insurance cards to other people
  • Members abusing their benefits by seeking drugs or services that are not medically necessary

Why should I care about fraud, waste, and abuse?

Fraud, waste, and abuse affect both health plan members and health care providers. They can:

  • Keep you from getting medical services.
  • Limit your health care benefits.
  • Keep providers from being paid for services.
  • Contribute to rising health care costs.

In addition, health care fraud is a real crime with real consequences. It could lead to fines or even jail time.

Here are some things that will help with the investigation:

  • Contact information (e.g., name of person making the report, address, phone number). While this helps, you do not need to provide it if you do not wish to do so.
  • Description of the possible fraud or abuse
  • Time frame of the possible fraud or abuse
  • Name and ID number of the suspected person
  • Source of the complaint, including the type of item or service involved in the possible fraud or abuse
  • Approximate dollar amounts involved, if known
  • Place of service
Members