Submit an anonymous report

Preventing Fraud, Waste, and Abuse

Fraud is generally defined as making a false claim in order to receive a payment. For example, fraud in the healthcare industry can involve:

• Billing for medical services that weren't ordered or provided

• Billing for durable medical equipment items that weren't ordered or provided

• Providing services or items a person doesn't need based on his or her medical history

• "Doctor shopping" – when a patient who may or may not have a legitimate physical ailment goes from doctor to doctor to obtain multiple prescriptions for narcotic painkillers

To protect yourself from possible fraud, carefully read and review your Explanation of Benefits (EOB) after you receive healthcare services. If something doesn’t look right to you, let us know about the potential error as soon as possible.

Waste is generally defined as overusing services or a misuse of resources that result in unnecessary costs to the Medicare Program.

• Conducting excessive office visits or writing excessive prescriptions

• Prescribing more medications than necessary for the treatment of a specific condition

• Ordering excessive laboratory tests

Abuse is generally defined as payment for items or services when payment is not allowed and the provider has not knowingly misled the Plan or Medicare.

• Billing for unnecessary medical services

• Billing for brand-name drugs when generics are dispensed

• Charging excessively for services or supplies

• Misusing codes on a claim, such as up-coding or unbundling codes

Any individual, entity, or group that is employed by or provides a service for Elite Health Plan (including employees, members, professional providers, employees of a provider, facilities, vendors, etc.) may be the subject of the complaint.