Health care fraud, waste and abuse affects everyone. It can happen anywhere and results in higher healthcare costs to all of us. It is important for patients and providers to know what health care fraud, waste and abuse is, how to identify it, and how to report it.
Definitions of Fraud, Waste and Abuse
“Fraud” is 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.
“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.
“Abuse” is 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.
Some examples of fraud, waste and abuse are:
- A health care provider bills for services that were never provided to a patient.
- A supplier bills for equipment or supplies that were never received.
- Someone uses another person’s ID card to receive services covered by Medicare.
- A health care provider bills for services more than once when the service was only provided once.
- Someone alters a prescription that was written by their doctor.
- A health care provider or supplier offers money or gifts as an incentive to receive healthcare services that are not medically necessary.
- Someone makes false statements to receive medical or pharmaceutical services.
Reporting Fraud, Waste and Abuse
RxLive encourages all patients and requires providers it works with to report all cases of suspected fraud, waste and abuse. If you know of any patient, providers, hospitals, or pharmacies who you suspect have committed fraud, waste or abuse, you can report them using the process described below. You can even report anonymously if you’d like.
Reporting to RxLive
If you believe you have seen any fraud, waste or abuse activities, you can contact us immediately at 1-866-234-4974 (TTY 711), Monday – Friday, 8 a.m. to 6 p.m. EST. We will conduct a thorough investigation and work with appropriate State and Federal agencies to make sure your rights and services are protected to the fullest extent possible
You may also make a report anonymously using the link below:
Reporting to the State/Federal Government Agencies
You can report your concerns to your local Health Department, or you can make a report directly to:
U.S. Department of Health and Human Services
Office of Inspector General (OIG)
Phone: 1-800-HHS-TIPS (447-8477)
Address: US Department of Health and Human Services
Office of Inspector General
ATTN: OIG HOTLINE OPERATIONS
P.O. Box 23489
Washington, DC 20026
False Claims Act
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 Act allows a person with knowledge of fraud against the United States Government (or Medicare) 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 known as a “whistleblower” case. If the lawsuit is successful, the whistleblower may be 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 RxLive Compliance Officer at 1-866-234-4974 (TTY 711) or by email at Compliance@RxLive.com.