Health care fraud, waste and abuse hurts everyone including members, providers, taxpayers and CareSource. As a result, CareSource has a comprehensive fraud, waste and abuse program in our Special Investigations Department. Help us by reporting questionable situations.
Some examples of Provider activity that is monitored for fraud and abuse:
- Prescribing drugs, equipment or services that are not medically necessary
- Failing to provide patients with medically necessary services due to lower Medicaid/Medicare reimbursement rates
- Requiring members to pay for CareSource covered services
- 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
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
Examples of member Fraud, Waste and Abuse:
- 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)
It is also important for you to tell us if a CareSource employee acts inappropriately. Some examples are:
- Receiving gifts or kickbacks from vendors for goods or services purchased by CareSource
- Inappropriately marketing our company to potential members
- Behaving in an unethical or dishonest manner while performing company business
Corrective action of any identified Fraud, Waste and/or Abuse are available in our Provider Manual. For provider terminations/suspensions information, the CareSource Fair Hearing Plan is available on this website.
You can report fraud, waste and abuse to CareSource by:
Options for reporting anonymously:
- Call: 1-800-488-0134 and follow the prompts to report fraud
Attn: Special Investigations Unit
P.O. Box 1940
Dayton, OH 45401-1940
- Complete the Fraud, Waste and Abuse Reporting Form
Options for reporting that are not anonymous:
- Fax: 1-800-418-0248
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 out of health care. CareSource is required to provide you with information on the False Claims Act, please see details below.
False Claims Act
Visit False Claims Act for more information.
Prohibited Affiliations / 42 C.F.R. § 438.610
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.
Avoiding Medicare and Medicaid Fraud and Abuse from the OIG
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