Fraud Waste and Abuse

Help QHPNY Prevent Fraud Waste & Abuse!

Every year, millions of Medicare dollars are lost to fraud, waste and abuse. You can do your part to help prevent it from happening by watching out for and reporting fraud when you see it being committed.

Fraud is generally defined as making a false claim to receive payments.

Examples of Medicare fraud can involve:

  • ‘Doctor shopping’‐ when a patient who may or may not have a legitimate physical ailment goes from doctor to doctor to obtain many prescriptions for narcotic painkillers.
  • Someone obtains Rx drugs from a provider, possibly for a condition they don’t have and gives or sells the medication to someone else.
  • Inappropriate consumption or distribution of a consumer’s medications by a caregiver or anyone else.
  • A person uses another’s Medicare card to obtain services or prescriptions.

 

IF YOU SUSPECT FRAUD WASTE & ABUSE, PLEASE REPORT IT!

Call the QHPNY Compliance Hotline @ 1‐877‐303‐1768 or e‐mail compliancemail@qualityhealthplansny.com.
Anonymous and Confidential

Remember that all reports of suspected incidences are kept confidential.

Note: There is no retaliation against someone who reports a compliance of FWA concern in good faith.

How can I protect myself and Medicare from fraud?

Medicare fraud and abuse can cost taxpayers billions of dollars each year. One common form of Medicare fraud is when a provider bills Medicare for services you never got. When you get health care services, record the dates on a calendar and save the receipts and statements you get from providers to check for mistakes. If you think you see an error or are billed for services you didn’t get, take these steps to find out what was billed:

  • Check your “Medicare Summary Notice” (MSN) if you have Original Medicare to see if the service was billed to Medicare. If you’re in a Medicare health plan, check the statements you get from your plan.
  • If you know the health care provider or supplier, call and ask for an itemized statement. They should give this to you within 30 days.
  • Visit MyMedicare.gov to view your Medicare claims if you have Original Medicare. Your claims are generally available online within 24 hours after processing. You can also download your claims information by using Medicare’s Blue Button. See page 103. You can also call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

If you’ve contacted the provider and you suspect that Medicare is being charged for a service or supply that you didn’t get, or you don’t know the provider on the claim, call 1-800-MEDICARE.  Know your rights & protect yourself from fraud.

For more information on protecting yourself from Medicare fraud and tips for spotting and reporting fraud, visit Medicare.gov, or contact your local Senior Medicare Patrol (SMP) Program. For more information about the SMP program, visit smpresource.org or call 1-877-808-2468. You can also visit oig.hhs.gov or call the fraud hotline of the Department of Health and Human Services Office of the Inspector General at 1-800-HHS-TIPS (1-800-447-8477). TTY users can call 1-800-377-4950.

Plans must follow rules

Medicare plans must follow certain rules when marketing their plans and getting your enrollment information. They can’t ask you for credit card or banking information over the phone or via email, unless you’re already a member of that plan. Medicare plans can’t enroll you into a plan over the phone unless you call them and ask to enroll, or you’ve given them permission to contact you.

Call 1-800-MEDICARE to report any plans that:

  • Ask for your personal information over the phone or email
  • Call to enroll you in a plan
  • Use false information to mislead you

You can also call the Medicare Drug Integrity Contractor (MEDIC) at 1-877-7SAFERX (1-877-772-3379). The MEDIC helps prevent inappropriate activity and fights fraud, waste, and abuse in Medicare Advantage (Part C) and Medicare Prescription Drug (Part D) Programs.

Fighting fraud can pay

You may get a reward if you help us fight fraud and meet certain conditions. For more information, visit Medicare.gov, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

Investigating fraud takes time

 Every tip counts. Medicare takes all reports of suspected fraud seriously. When you report fraud, you may not hear of an outcome right away. It takes time to investigate your report and build a case, but rest assured that your information is helping us protect Medicare.

From Medicare and You 2019

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