Community Care

Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.

Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Abuse includes any action(s) that may, directly or indirectly, result in one or more of the following:

• Unnecessary costs to the health care system
• Improper payment for services
• Payment for services that fail to meet professionally recognized standards of care
• Services that are medically unnecessary

Fraud, waste and abuse takes many forms. The most common of these forms include:

Providers

• Billing for services that were not provided
• Duplicate submission of a claim for the same service
• Misrepresenting the service provided
• "Upcoding" — charging for a more complex or expensive service than was actually provided
• Billing for a covered service when the service actually provided was not covered
  
  

Members

• Using a member ID card that does not belong to that person
• Adding someone to a policy that is not eligible for coverage (i.e., grandchildren)
• Failing to remove someone as a beneficiary when that person is no longer eligible (i.e., a former spouse)
• "Doctor shopping" — visiting several doctors to obtain multiple prescriptions

Health care fraud, waste and abuse is a national problem and your assistance is vital in helping us to prevent the problem. Simple tips that may help you prevent fraud and abuses include:

• Review your Explanation of Benefits to ensure accurate dates of service, name of providers, and types of services reported
• Protect your insurance card and personal information at all times
• Count your pills each time you pick up a prescription
• Research providers with your state medical board
• Report suspected fraud and abuse as soon as possible

Complete and submit the Program Integrity Fraud, Waste and Abuse Complaint Form, VA Form 10-0500, via email to the Program Integrity Team. You can also download, print and return the form by mail or fax to the address and fax number included on the form. We will make every effort to keep all information we receive confidential.

Before you report fraud, waste and abuse, carefully review the facts and have the following information ready:

• The provider’s name and any identifying number you may have
• Information on the service or item you are questioning
• A copy of your health care program’s Explanation of Benefits regarding the date of service
• The payment amount approved and paid by your health care program
• The reason you think your health care program should not have paid
• Any other additional information you have showing why your health care program should not have paid