Fraud, Waste and Abuse (FWA)

CareSource is required to prevent, identify, investigate, correct and report (FWA).  As a CareSource FDR, you share these same responsibilities and requirements.  In order for you to be able to carry out these duties, we are providing the following list as examples of Fraud, Waste, and Abuse.  Please note that this list is in no way complete and should not be considered a definitive list of FWA.  If you have any questions or concerns you can contact CareSource for further information at:

  • Fraud Hotline: 1-800-488-0134 (Follow the prompts for reporting Fraud)
  • Written Report: Use the Fraud, Waste and Abuse Reporting Form on www.caresource.com or write a letter and send to:
    • CareSource
      Attn:  Special Investigations Unit
      P.O. Box 1940
      Dayton, OH 45401-1940

Options for reporting that are not anonymous:

Fraud Waste and Abuse can be witnessed at all levels of an organization.

Below are some examples of fraud, waste and abuse. If you have any questions about these examples or Fraud, Waste and Abuse in general, please send an email to: Fraud@CareSource.com.


Provider:

  • Billing for non-covered, medically unnecessary services and prescription drugs
  • Up-coding CPT, HCPCS and DRG codes to obtain a higher rate of reimbursement
  • Separating and billing the individual components of a medical service rather than correctly billing with an all-inclusive procedure code – also known as “unbundling”
  • Inappropriate use of CPT codes and/or modifiers to seek higher reimbursement
  • Not checking a member’s identification card, resulting in claims submitted for non-covered persons
  • Billing for services not rendered
  • Balance billing of Medicaid members for any balance owed after CareSource has paid the approved state fee for services rendered
  • Retaining payments made in error by CareSource
  • Payments stemming from kickbacks or Federal Stark Law violations
  • Duplicate payments for services

Member:

  • Inappropriate use of Medicaid/Medicare purchased narcotics
  • Forging prescriptions to obtain controlled substances
  • Sharing CareSource ID cards with nonmembers
  • Submitting fraudulent Babies First Coupons for prenatal and well-baby visits (Medicaid Only)
  • Misusing ID card
  • Submitting false information

Pharmacy:

  • Dispensing prescription drugs inconsistent with the order
  • Submitting claims for a more expensive brand drug when a less expensive generic prescription is dispensed
  • Dispensing less than the prescribed quantity without arranging for the additional medication to be received with no additional dispensing fees
  • Splitting prescriptions into two orders to seek higher reimbursement
  • Dispensing expired, fake, diluted, tainted or illegal drugs
  • Billing for prescriptions not filled or picked up

Company/Employee/Delegated Entities:

  • Embezzling CareSource funds
  • Misappropriation of CareSource assets
  • Stealing CareSource property
  • Falsifying CareSource business data and reports
  • Receiving gifts or kickbacks from vendors for goods or services
  • Preventing members from accessing covered services resulting in underutilization of services offered
  • Altering/destroying member materials, medical records, etc.
  • Backdating forms

The Federal False Claims Act:

Using the False Claims Act (the Act), you can help reduce fraud against the federal government.  The Act allows everyday people to bring “whistleblower” lawsuits on behalf of the government known as “qui tam” suits against businesses or other individuals that are defrauding the government through programs, agencies or contracts.

The False Claims Act applies when a company or person:

  • Knowingly presents or causes to be presented, a false or fraudulent claim for payment or approval;
  • Knowingly makes, uses or causes to be made or used, a false record or statement material to a false or fraudulent claim;
  • Conspires to commit a violation of any other section of the False Claims Act;
  • Has possession, custody or control of property or money used, or to be used, by the government and knowingly delivers, or causes to be delivered, less than all of that money or property;
  • Is authorized to make or deliver a document certifying a receipt of property used, or to be used by the government, and intending to defraud the government, makes or delivers the receipt without completely knowing that the information on the receipt is true;
  • Knowingly buys or receives as a pledge of an obligation or debt, public property from an officer or employee of the government, or a member of the Armed Forces, who lawfully may not sell or pledge property; or
  • Knowingly makes, used or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the government, or knowingly conceals or improperly avoids or decreases an obligation to pay or transmit money or property to the government.

“Knowingly” means acting with actual knowledge or with reckless disregard or deliberate indifference to the truth or falsity of information.

The time period for a claim to be brought under the False Claims Act is the later of:

  • Within six years from the date of the illegal conduct, or
  • Within three years after the date the Government knows or should have known about the illegal conduct, but in no event later than ten years after the illegal activity

There are significant penalties for violating the False Claims Act.  Civil penalties include fines for each false claim and may be tripled.  In addition to civil penalties, courts can also impose criminal penalties.

Ohio Law:

While Ohio has not passed its own false claims statute, there may nevertheless be liability under various Ohio laws regarding false or fraudulent claims with respect to Medicaid/Medicare program expenditures, including:

  • Medicaid Fraud, Ohio Revised Code Sec. 40
  • Medicaid Eligibility Fraud, Ohio Revised Code Sec. 401
  • Falsification, Ohio Revised Code Sec. 13
  • Offenses by Medicaid Providers, Ohio Revised Code Sec. 35

Fraud, Waste and Abuse Reporting Process:

It is CareSource’s policy to detect and prevent any activity that may constitute fraud, waste or abuse, including violations of the Federal False Claims Act or any other federal or state fraud laws.  If you have knowledge or information that any such activity may be or has taken place, please contact our Special Investigations Unit using the contact information in this letter.  Information may be reported anonymously.

Your organization must emphasize non-retaliation and non-intimidation for good-faith reporting of allegations of noncompliance and potential fraud, waste and abuse.  You must have one or more methods to anonymously report noncompliance and fraud, waste and abuse to CareSource, and these methods must be widely publicized and available to employees 24 hours per day, seven days per week.  Your organization should have a system in place to receive, record, respond and track issues of this nature.

Options for reporting anonymously:

  • Fraud Hotline: 1-800-488-0134 (Follow the prompts for reporting Fraud)
  • Written Report: Use the Fraud, Waste and Abuse Reporting Form on www.caresource.com or write a letter and send to:
    • CareSource
      Attn:  Special Investigations Unit
      P.O. Box 1940
      Dayton, OH 45401-1940

Options for reporting that are not anonymous:

Protections for Reporters of Fraud, Waste and Abuse:  

Federal and state law and CareSource’s policy prohibit any retaliation or retribution against persons who report suspected violations of these laws to law enforcement officials or who file “whistleblower” lawsuits on behalf of the government.  Anyone who believes that he or she has been subject to any such retribution or retaliation should also report this to the Special Investigations Unit using the contact information in this letter.

Federal and State False Claims Acts and our Fraud, Waste and Abuse reporting mechanisms can also be found on our website, www.caresource.com.


Other Fraud, Waste and Abuse Laws:

  • Under the Federal Anti-Kickback Statute, and subject to certain exceptions, it is a crime for anyone to knowingly and willfully solicit or receive, or pay anything of value, including a kickback, bribe or rebate in return for referring an individual to a person for any item or service for which payment may be made in whole or in part under a federal health care program. 42 U.S.C §1320a-7b.
  • Under the Federal Stark Law, and subject to certain exceptions, physicians are prohibited from referring federal health care program patients for certain designated health services to an entity with which the physician or an immediate family member has a financial relationship. The Stark Law imposes specific reporting requirements on entities that receive payment for services covered by federal health care programs. 42 U.S.C §1395(a) and 1903(s).