Fraud, Waste, and Abuse

You Can Help Prevent Health Care Fraud, Waste, and Abuse.

The National Health Care Anti-Fraud Association (NHCAA) estimates that about $100 million is lost from health care fraud each day! You can help Clever Care Health Plan to prevent, detect, and correct health care fraud by reporting any suspicious activity. When you report a situation that may be potential health care fraud, waste, and abuse, you are essentially helping to make our health care system better.

 

What is Health Care Fraud, Waste and Abuse?

  • Fraud occurs when someone knowingly and willfully submits a false claim that results in inappropriate payments.
  • Waste is overuse of services or other practices that, directly or indirectly, results in unnecessary medical costs. This includes the misuse of resources which is not generally considered a criminally negligent action.
  • Abuse is an action that may result in unnecessary medical costs. When a person or entity unknowingly or purposely misrepresents fact to obtain payment, this is abuse.

 

Health Care Fraud, Waste, and Abuse Examples

Health care fraud, waste and abuse can take many forms, which makes it hard to spot. Here is a breakdown of the most common types.

Fraud

  • Billing for services not rendered
  • Falsifying a patient’s diagnosis to justify unnecessary procedures
  • Accepting kickbacks for patient referrals.

Waste

  • Ordering excessive diagnostic tests
  • Overuse of office visits
  • A pharmacy sending medications to members without confirming they still need them.

Abuse

  • Charging in excess for services or supplies
  • Providing medically unnecessary services
  • Going to different doctors or emergency rooms to obtain pain medication.

It is important to know how to recognize fraud, waste, and abuse— and learn how to protect yourself and others from becoming victims. Learn how to better recognize fraud, waste, and abuse by reviewing our Frequently Asked Questions.

 

Report Potential Fraud, Waste and Abuse (FWA)

You are our best ally when it comes to preventing health care FWA. If you suspect an incident is FWA, you have several ways to report it.

Frequently Asked Questions

Fraud occurs when someone knowingly and willfully submits a false claim that results in inappropriate payments.

Waste is overuse of services or other practices that, directly or indirectly, results in unnecessary medical costs. This includes the misuse of resources which is not generally considered a criminally negligent action.

Abuse is an action that may result in unnecessary medical costs. When a person or entity unknowingly or purposely misrepresents fact to obtain payment, this is abuse.

  • Protect your Clever Care ID card like you would a credit card. Be careful about disclosing your personal information. If you lose your Clever Care ID card, report it to us immediately.
  • Review your explanation of benefits (EOB) routinely and make sure everything is accurate.
  • If you suspect you may be a victim of health insurance fraud, report it immediately.
  • Be informed about the health care services you receive, keep good records of your medical care, and review all medical bills you receive.
  • Shred your medical bills and records when you dispose of them.
  • Beware of “free” offers. Offers of free health care services, tests, or treatments are often fraud schemes designed to bill you and your insurance company illegally for treatments you never received.

Yes. When you report health care fraud to Clever Care, any personal information you provide will stay confidential. You may also choose not to disclose your personal information when completing the form.

Anyone can report health care fraud, waste, and abuse through this Clever Care site. You do not have to be a Clever Care member or provider.

When people claim to be from a trustworthy entity or group in order to get your personal information, they are committing a phishing scam. Phishing tries to obtain information like credit card details, Social Security numbers, and health information to use in fraudulent activity or theft.

Clever Care will never ask you for your passwords, Social Security number, or financial information.

Here are some ways to protect yourself from phishing scams:

  • Do not give your personal information to anyone who calls or emails you.
  • Proceed with caution – do not make any decisions before investigating the details.
  • Never email personal or financial information unless it is secure.
  • Always safeguard your member ID card. Try not to give information on your member ID card to anyone other than your doctor, hospital, or pharmacy.
  • Make a report to your local sheriff or police department. Make sure to keep a copy of the police report for your records.
  • Report it to the Federal Trade Commission’s Identity Theft Hotline: 1-877-IDTHEFT (1-877-438-4338).
  • Report the matter to Clever Care so we can issue you a new ID card with a new number and we can also help you monitor your claims activity.

You can call the number on the back of your ID card or contact our Member Services at (833) 388-8168. TTY Users Call: 711. Hours are 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, and 8 a.m. to 8 p.m., weekdays, from April 1 through September 30. Messages received on holidays or outside of our business hours will be returned within one business day.

Member Services can help you with explaining bills, claims and coverage. They can also help to find you network providers, like doctors, clinics, or hospitals.