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

When you report a situation that may be fraud, you’re doing your part to improve the health care system. If you suspect fraud, waste, or abuse, you can report it to us online:

Report Online

Or via email, mail, or fax:

Potential Fraud Report

Resources To Learn More

DID YOU KNOW...?

Stay on Top of Your Prescriptions

Woman grabbing a prescriptionDid you know that certain prescription medicines are available as a 90-day supply? Medicine that you take on a long-term basis to manage your health is called a “maintenance drug.” A 90-day supply makes it easier to keep taking the medicine you need to feel your best. You may also be eligible to receive your long-term medications through free home delivery.

LEARN MORE

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