Fraud, Waste & Abuse

Our Program Integrity Department handles cases of fraud, waste, or abuse. It can be done by providers, pharmacies, or members.

  • Fraud means the purposeful misuse of or for gain of benefits.
  • Waste means overusing benefits when they are not needed.
  • Abuse is action that causes unneeded costs to HAP CareSource.

Examples of Fraud, Waste, or Abuse

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

Reporting Options

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* or fax. 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.

*Others may read your email without you knowing or saying it is okay if your email is not secure. Please do not use email to send a member ID number, social security number or any health information. Please use the form or phone number above. This can help protect your privacy.

Member Services: 1-833-230-2053 (TTY: 711), 24 hours a day, seven days a week.