Fraud, Waste, and Abuse
Definition of fraud
The Centers for Medicare & Medicaid Services (CMS) defines fraud as any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in an unauthorized benefit to themselves or some other person. It includes any act that constitutes fraud under applicable state or federal law.
Definition of abuse
CMS defines abuse as provider practices that are inconsistent with sound fiscal, business, or medical practice and result in unnecessary cost to the Medical Assistance program, or in reimbursement for services that are not medically necessary, or that fail to meet professionally recognized standards or contractual obligations. It also includes recipient practices that result in unnecessary cost to the Medical Assistance program.
Examples of fraud and abuse by providers are:
- Billing or charging Medical Assistance recipients for covered services.
- Billing more than once for the same service.
- Dispensing generic drugs and billing for brand name drugs.
- Falsifying records.
- Performing inappropriate or unnecessary services.
- Failure to complete clinical medical record documentation.
- Falsification or back dating of clinical record entries.
- Falsifying information on their enrollment form.
- Billing one family therapy session held with several members as several hours of individual therapy.
Some examples of fraud and abuse by members are:
- Sharing a Medical Assistance card with another so a non-member can receive services.
- Seeking drugs or services that members do not need.
- Requesting medical care that is not needed.
- Falsifying information on an enrollment form.
Indicators of provider fraud and abuse that you could report to your managed care company (MCO):
- When members are asked to sign blank encounter forms.
- When the provider does paperwork during session time and does not work directly with the member or their family.
- When the provider is frequently late or leaves earlier than the scheduled appointment.
- When one provider frequently attends routine physical health or behavioral health appointments that a member holds with a different service provider.
- When providers make frequent unscheduled visits to a member's home and/or spends the majority of the time discussing topics unrelated to the treatment/service plan.
Indicators of fraud and abuse by members are:
- Using more than one Social Security number or name.
- Not being able to prove their identity.
- Requesting services or medication that the member feels may not be medically necessary.
How do I report an allegation of fraud, waste, and abuse?
All providers are obligated by the provider agreement to designate a compliance officer and notify PerformCare of any suspected fraud or abuse involving their members. The designated corporate compliance officer should report such incidents within 72 hours when learning of a potential incident. PerformCare compliance staff will work with each provider to develop a self-report audit plan, as well as a follow up corrective action plan to prevent future occurrence of any confirmed violation.
Reports can be submitted to PerformCare via mail, email, or phone.
8040 Carlson Road
Harrisburg, PA 17112
You have the option to submit an additional report to the agencies below by calling their toll-free number at any time:
- Department of Human Services Bureau of Program Integrity hotline at 1-844-DHS-TIPS (1-844-347-8477).
- AmeriHealth Caritas tips hotline (PerformCare's parent company): 1-866-833-9718.
- Contacting the Department of Human Services by visiting their website or sending them an email.
Reports may be made anonymously to all entities.