Fraud, Waste & Abuse

Medicaid can be misused, ending in fraud, waste, or abuse. It can be done by providers, drugstores, or members. Help us by letting us know if you suspect fraud, waste, or abuse. It is handled by CareSource’s Program Integrity. Examples are listed below.

Providers who:

  • Order drugs, equipment or services that are not medically necessary
  • Don’t give medically necessary services due to lower reimbursement rates
  • Bill for tests or care not provided
  • Use wrong medical coding on purpose to get more money
  • Plan more visits than are needed
  • Bill for more expensive care than provided
  • Unbundle services to get a higher repayment

Members who:

  • Sell prescribed drugs or try to get controlled drugs from more than one doctor or drugstore
  • Change or forge prescriptions
  • Use pain medications they do not need
  • Share their ID card with someone else
  • Don’t tell us that they have other health insurance
  • Get equipment and supplies they don’t need
  • Get care or drugs under some other person’s ID
  • Give wrong symptoms to get treatment, drugs, and other care
  • Have too many ER visits for problems that are not an emergency
  • Lie about eligibility for Medicaid

Pharmacies that:

  • Don’t give drugs as written
  • Send claims for a brand-name drug that costs more but give a cheaper drug that costs less
  • Give less than the prescribed amount and not letting you know to get the rest of the drug

Do You Suspect Fraud, Waste or Abuse?

If you think a provider or a CareSource member is committing fraud, waste or abuse, you can report your concerns to us by:

  • Call 1-855-202-0729 (TTY: 1-800-255-0056 or 711). Select the menu choice to report fraud. Our Fraud, Waste, and Abuse hotline is available 24 hours a day
  • Completing the NavigateFraud, Waste and Abuse Reporting Form and mailing it to:
    CareSource Attn: Program Integrity
    P.O. Box 1940
    Dayton, OH 45401-1940

You do not have to give us your name when you write or call. If you are not concerned about giving your name, you may also send an email* to fraud@caresource.com or fax us at 1-800-418-0248. Please give us as many facts as you can. Add names and phone numbers. If we don’t get your name, we will not be able to call you back for more information. This will be kept private as allowed by law.

*If your email is not secure, people may read your email without you knowing or saying it is okay. Please do not use email to tell us anything private, like a member ID number, social security number, or health information. Instead, please use the form or phone number above. This can help protect your privacy.

How Can You Protect Yourself Against Fraud?

Below are a few simple tips to help protect you against health care fraud:

  • Treat your member ID card like you would a credit card. Don’t give out policy numbers to door-to-door salespeople, over the phone or on the internet. Watch out for people trying to offer you money or other free items for your personal information.
  • Beware of any offers for free services or items (food, gas, gift cards, etc.) in exchange for your CareSource ID number.
  • Do not sign your name to a blank form. If you have questions about what you are signing, be sure to ask your health partner.
  • Read your Explanation of Benefit (EOB) statements and any papers you receive from CareSource. Are there any services, supplies or equipment listed that you did not receive? Are there any services that were billed more than once but you received only once? Did you get services on all the dates of service that are shown? If you suspect an error or fraud, report it to us using one of the methods above.

Thank you for helping CareSource keep fraud, waste and abuse out of health care.

Member Services: 1-855-202-0729 (TTY: 1-800-255-0056 or 711), Monday – Friday 7 a.m. – 7 p.m.