Understanding Fraud, Waste, and Abuse
Fraud, waste, and abuse (FWA) impact everyone in the healthcare system, from members and providers to health plans and taxpayers. Recognizing these behaviors is the first step toward preventing them.
1. Fraud
Fraud is the intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to themselves or some other person. Examples include:
- Billing for services or supplies that were never provided.
- Using someone else’s member ID card to obtain medical care.
- Providing false information to qualify for coverage.
- Altering medical records or prescriptions to obtain medications.
2. Waste
Waste involves the overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system. It is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources. Examples include:
- Ordering excessive or redundant diagnostic tests.
- Prescribing brand-name drugs when a generic equivalent is more cost-effective and appropriate.
- Scheduling unnecessary follow-up visits.
3. Abuse
Abuse describes practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the healthcare program, or in reimbursement for services that are not medically necessary. Examples include:
- Billing for services that were not medically necessary.
- Misusing codes on a claim, such as upcoding or unbundling.
- Providing services that do not meet professionally recognized standards of healthcare.
Reporting suspected fraud, waste, or abuse is essential to maintaining the integrity of our healthcare system. If you see something that doesn't seem right, please use the reporting tool below.
Report Fraud, Waste, or Abuse
Use this form to report suspected Fraud, Waste, or Abuse. You may submit anonymously or share your contact information if you’d like us to follow up.