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Examples of Fraud, Waste and Abuse

Provider Fraud:

  • Billing for services not rendered
  • Altering medical records
  • Use of unlicensed staff
  • Drug diversion (e.g. dispensing controlled substances with no legitimate medical purpose)
  • Kickbacks and bribery
  • Providing unnecessary services to members

Member Fraud:

  • Falsification of information
  • Forging or selling prescription drugs
  • Using transportation benefit for non-medical related business (Advantage)
  • Adding an ineligible dependent to the plan
  • “Loaning” or using another person’s insurance card
  • Identity Theft

Broker and Agent Fraud:

  • Alteration of documents
  • Bribery and kickbacks
  • Falsification or misrepresentation of member and or group information to obtain reasonable rates. This act makes the applicant for coverage appear to be a better risk for policy acceptance.
  • Failure to disclose information that may affect conditions of coverage
  • Sale of non-existent policies

Part D Medicare Prescription Drug Benefit Fraud, Waste or Abuse:

  • An individual or organization pretends to represent Medicare and/or Social Security, and asks you for your Medicare or Social Security number, bank account number, credit card number, money, etc.
  • Someone asks you to sell your Medicare prescription drug card
  • You feel a Medicare prescription Drug Plan has discriminated against you, including not letting you sign up for their plan because of your age, health, race, religion, income
  • You were encouraged to disenroll from your plan
  • You were offered cash to sign up for a Medicare prescription drug plan
  • You were offered a gift worth more than $15 to sign up for a Medicare prescription drug plan
  • Your pharmacy did not give you all of your drugs
  • You were billed for drugs that you didn’t receive
  • You believe that you have been charged more than once for your premium costs
  • Your Medicare prescription drug plan did not pay for your covered drugs
  • You received a different drug than your doctor ordered