Fraud, Waste, and Abuse - Community Health Plan of Washington - Medicare Advantage

Fraud, Waste, and Abuse

You Can Help Prevent Health Care Fraud.

The National Health Care Anti-Fraud Association estimates that the financial losses from health care fraud are about $100 million per day. Community Health Plan of Washington is committed to doing all we can to prevent, detect, and correct health care fraud. When you report a situation that may be potential health care fraud, you’re doing your part to help save money for the health care system.

What is Health Care Fraud, Waste and Abuse?

Fraud

Fraud occurs when someone knowingly and willfully submits a false claim that results in inappropriate payments.

Examples: Billing for services not rendered, falsifying a patient’s diagnosis to justify unnecessary procedures, or accepting kickbacks for patient referrals.

Waste

Waste is overuse of services or other practices that, directly or indirectly, results in unnecessary medical costs. This includes the misuse of resources which is not generally considered a criminally negligent action.

Examples: Ordering excessive diagnostic tests, overuse of office visits, or a pharmacy sending medications to members without confirming they still need them.

Abuse

Abuse is an action that may result in unnecessary medical costs. When a person or entity unknowingly or purposely misrepresents fact to obtain payment, this is abuse.

Examples: Charging in excess for services or supplies, providing medically unnecessary services, or going to different doctors or emergency rooms to obtain pain medication.

Report Potential Fraud

If you feel you have witnessed fraud you can submit a report to CHPW via email, fax, or mail using contact information on the form. If you suspect fraud or want to report suspicious activity, you can also call Customer Service 1-800-942-0247 (TTY 711) from 8:00 a.m. to 8:00 p.m., seven days a week. You can remain anonymous while reporting fraud. Customer service will not ask for any personally identifiable information during a fraud report call. Any information you choose to provide will stay confidential.

Resources To Learn More

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Get to Know HealthPoint

One of our community health center partners, HealthPoint has many locations across King County. Their approach to health care is to bring together all the services someone needs to be healthy, in one place. We support their model of whole person care and together, our goal is healthier people and a healthier community.

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