Fraud, Waste & Abuse
Health care fraud, waste and abuse hurts everyone including members, providers, taxpayers and Humana – CareSource. As a result, Humana – CareSource has a comprehensive fraud, waste and abuse program in our Special Investigations Unit. Please help us by reporting questionable activities and potential fraud, waste and abuse situations.
Provider Fraud, Waste & Abuse
Some examples of provider activity that is monitored for fraud, waste and abuse:
- Prescribing drugs, equipment or services that are not medically necessary
- Billing more than once for the same service
- Intentionally using improper medical coding to receive a higher rate of reimbursement
- Billing for services not provided
- Scheduling more frequent return visits than are needed
- Unbundling services to obtain higher reimbursement
- Purchasing drugs from outside the U.S.
- Prescribing high quantities of controlled substances without medical necessity
- Billing for services outside of your medical qualifications
- Using enrollee lists for the purpose of submitting fraudulent claims
- Billing inpatients for drugs as if they were outpatients
- Receiving payments stemming from kickbacks or Stark Violations
- Retaining overpayments made in error by Humana – CareSource
- Preventing members from accessing covered services, resulting in underutilization of services offered
- Not checking member IDs, resulting in claims submitted for non-covered persons
- Failing to provide patients with medically necessary services due to lower Medicaid/Medicare reimbursement rates
- Requiring members to pay for covered services
Member Fraud, Waste & Abuse
Humana – CareSource monitors member activity for fraud, waste and abuse. Some examples are:
- Inappropriately using services such as selling prescribed narcotics, or seeking controlled substances from multiple providers or multiple pharmacies
- Sharing a member ID card
- Obtaining unnecessary equipment/supplies
- Changing prescription forms to get more than the amount of medication prescribed by their physician
- Member receiving services or picking up prescriptions under another person’s ID (identity theft)
- Not disclosing other health insurance coverage
- Providing inaccurate symptoms and other information to providers in order to get treatment, drugs, etc.
- Misrepresenting eligibility for Medicaid
- Misuse or abuse of covered benefits (e.g., prescriptions, emergency room visits, etc.) may be grounds for our Kentucky Lock-In Program (KLIP).
Pharmacy Fraud, Waste & Abuse
Examples of pharmacy fraud, waste and abuse:
- Prescription drugs not dispensed as written
- Submitting claims for a more expensive brand name 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 or illegal drugs
- Billing for prescriptions not filled or picked up
It is also important for you to tell us if a Humana – CareSource employee acts inappropriately. Some examples are:
- Receiving gifts or kickbacks from vendors for goods or services purchased by Humana – CareSource
- Inappropriately marketing our company to potential members
- Behaving in an unethical or dishonest manner while performing company business
Report Fraud, Waste & Abuse
Options that are anonymous:
Write: Humana – CareSource
Attn: Special Investigations Unit
P.O. Box 1940
Dayton, OH 45401-1940
Options that are not anonymous:
Please give a detailed description of the activity, including the:
- Provider/member/employee name
- Provider/member number, if available
- Date of activity
- Issue of concern
- All other pertinent information
Your report may be anonymous; however, if you do not provide your name, we will not be able to call you back for more information. Your message will be kept confidential to the extent permitted by law.
Thank you for your assistance in keeping fraud, waste and abuse out of health care.
False Claims Act
Humana – CareSource is required to provide you with information on the False Claims Act.
You can find more information about fraud, waste and abuse, including information about the federal and state False Claims Acts, Kentucky law, and other fraud, waste and abuse laws in our provider manual.
Visit False Claims Act for more information.
Prohibited Affiliations / 42 C.F.R. § 438.610
Humana – CareSource is prohibited by federal and/or state provider agreements from knowingly having relationships with persons who are debarred, suspended or otherwise excluded from participating in federal procurement and non-procurement activities. Relationships must be terminated with any trustee, officer, employee, provider or vendor who is identified to be debarred, suspended or otherwise excluded from participation in federal or state health care programs. If you or your office management employees are excluded, you must notify us immediately.
From the Office of the Inspector General
The Office of the Inspector General (OIG) has created free educational materials to assist in teaching physicians about the federal laws designed to protect Medicaid and Medicare programs and program beneficiaries from fraud, waste and abuse:
OIG Power Point:
A Roadmap for New Physicians