Fraud, Waste & Abuse
What Does Fraud, Waste and Abuse Look Like?
Health care fraud, waste and abuse can be committed by health partners, members or pharmacies. Examples include the following.
Health partners 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 that you did not have
- Use wrong medical coding on purpose to get more money
- Plan more visits than are needed
- Bill for more expensive care than you received
- Unbundle services to get a higher repayment
- Share their CareSource member ID card with another person
- Sell prescribed drugs or other medical equipment paid for by CareSource to others
- Provide inaccurate symptoms and other information to health partners to get treatment or drugs
- 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:
- Calling the Member Services number below and following the prompts for fraud. Our Fraud, Waste, and Abuse hotline is available 24 hours a day.
- Completing the Fraud, Waste and Abuse Reporting Form and mailing it to the address below
- Sending us a letter addressed to:
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. There are other ways you may contact us that are not anonymous. If you are not concerned about giving your name, you may also use one of the following means to contact us by:
- Email: email@example.com
- Fax: 1-800-418-0248
When you report fraud, waste or abuse, please give us detailed information that includes a clear description of what you believe has happened. Please also give us the names and phone numbers of those involved, if you have them. If you choose to remain anonymous, we will not be able to call you back for more information. Please leave as many details as possible. Your report will be kept confidential to the extent permitted by law.
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 member 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.
- 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: 1-855-202-0622 (TTY: 1-800-982-8771 or 711), Monday through Friday, 7 a.m. to 7 p.m.