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Fraud, Waste, and Abuse

Fraud is 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 includes practices that, directly or indirectly, result in unnecessary costs to the Medicare Program, such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.

Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves paying for items or services when there is no legal entitlement to that payment, and the provider has not knowingly or intentionally misrepresented facts to obtain payment.

Examples of Fraud:

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

Examples of Waste:

  • Conducting excessive office visits or writing excessive prescriptions
  • Prescribing more medications than necessary for treating a specific condition
  • Ordering excessive laboratory tests

Examples of Abuse:

  • Unknowingly billing for unnecessary medical services
  • Unknowingly billing for brand name drugs when generics are dispensed
  • Unknowingly excessively charging for services or supplies
  • Unknowingly misusing codes on a claim, such as upcoding or unbundling codes

How to report suspected FWA

Report suspected FWA by mail

Clever Care Health Plan
ATTN: Fraud, Waste, and Abuse
7711 Center Avenue, Suite 100
Huntington Beach, CA 92647

NOTE: Each reporting mechanism listed above are available 24 hours a day, 7 days a week.

Clever Care will not retaliate against you if you inform us, the federal government, state government, or any other regulatory agency with oversight authority of any suspected FWA.