Health care Fraud, Waste and Abuse affects each and every one of us. It is estimated to account for 3-10% of the annual expenditures of health care in the United States. It is important for members and providers to know what health care Fraud, Waste and Abuse is, how to spot it and methods to report it.
"Fraud" means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.
"Abuse" means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicare program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicare program.
"Waste" involves taxpayers not receiving reasonable value for money in connection with any government-funded activities due to an inappropriate act or omission by someone with control over or access to government resources. (e.g., executive, judicial or legislative branch employees, grantees or other recipients). Waste goes beyond fraud and abuse and most waste does not involve a violation of law. Waste relates primarily to mismanagement, inappropriate actions and inadequate oversight.
Some examples of Fraud, Waste and Abuse are:
MeridianCare strongly encourages members and requires providers to report all cases of suspected Fraud, Waste and Abuse. If you know of any MeridianCare
members, or providers, hospitals, or pharmacies who you suspect have committed Fraud, Waste or Abuse, you can report them using the process described below. You may report anonymously if you choose.
If you believe you have seen any Fraud, Waste or Abuse activities, you can contact us immediately at 1-855-580-1689 (TTY 711), Monday – Sunday, 8 a.m. to 8 p.m. We will conduct a thorough investigation and work with State and Federal government agencies to make sure your rights and services are protected to the fullest extent.
You may also report anonymously 24 hours a day 7 days a week at 1-855-375-6725 (TTY: 711), Monday - Sunday, 8 a.m. to 8 p.m. You may also visit our FWA Reporting Site at mhplan.ethicspoint.com.
Illinois State Police
Medicaid Fraud Control Unit
801 South Seventh Street – Suite 500A
Springfield , IL 62703
U.S. Department of Health and Human Services Office of Inspector General (OIG)
Address: US Department of Health and Human Services Office of Inspector General
ATTN: OIG HOTLINE OPERATIONS
PO Box 23489
Washington, DC 20026
The False Claims Act is aimed at establishing a law enforcement partnership between federal law enforcement officials and private citizens who learn of fraud against the Government. Under the False Claims Act, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds are liable for up to three times the government's damages plus civil monetary penalties. The False Claims Act explicitly excludes tax fraud.
The Act permits a person with knowledge of fraud against the United States Government to file a lawsuit on behalf of the Government against the person or business that committed the fraud. The lawsuit is known as a "qui tam" case, but it is more commonly referred to as a "whistleblower" case. If the lawsuit is successful, the qui tam plaintiff is rewarded with a percentage of the recovery, typically between 15 and 25%. Any person who files a qui tam lawsuit in good faith is protected by law from any threats, harassment, abuse, intimidation or coercion by his or her employer.
For more information on the False Claims Act, please contact the Meridian
Corporate Compliance Officer at1-855-580-1689 (TTY 711), Monday - Sunday from 8 a.m. – 8 p.m.
Page Last Modified: 11/20/2017 2:43:27 PM