Fraud, Waste and Abuse

What is healthcare fraud, waste and abuse (FWA)?

The following definitions and information will be helpful in understanding how the regulatory agencies interpret fraud waste and abuse.

Fraud – when a person or group of people attempt to do something to cheat any healthcare plan which causes the person or group of people to benefit from their actions.

Waste – the overutilization of services or practices that directly or indirectly result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Abuse – when something is done differently than is considered accepted practice.

Examples of FWA (Providers):

• Billing for services not actually performed.
• Upcoding – billing for a more costly service than the service actually performed.
• Unbundling – billing each step of a procedure as if it were separate instead of billing it under the procedure as a whole.
• Accepting kickbacks for member referrals.

Examples of FWA (Members):

• Using someone else’s insurance card.
• Providing false statements on an enrollment application such as dependent information to obtain health coverage.
• Using SummaCare as your primary insurance when another insurance carrier is your primary coverage.
• Using a false home address to obtain coverage when your primary address is out of the service area.

Help Fight Fraud, Waste and Abuse

1. Read you Explanation of Benefits (EOB) carefully.

This is your notification that SummaCare has been billed for services performed under your benefit plan. A few items to look for:

• Providers who did not see or treat you
• Services that you did not receive
• Incorrect dates of service.
• Errors that you identify on your EOB may not prove to be fraudulent situations. However, all reports of discrepancies are thoroughly investigated to determine if fraudulent activity does exist.
 
2. Report all possible cases of fraud, waste and abuse.

Call or write us to report fraud, waste or abuse. Call the SummaCare Compliance Hotline at 800-361-3908 (TTY 711) or 330-996-8821 (TTY 711) and leave a message that includes:

• The reason you believe a fraudulent or abusive situation has occurred
• Information regarding the situation in question
• The name of the individual, provider or group that may have committed fraud or abuse
• The date(s) the situation occurred
• Any other information you have that may help with the investigation
• You may leave your name and number or choose to remain anonymous

Write to us at: SummaCare Compliance Department F&A, P.O. Box 3620, Akron, Ohio 44309-3620

Download and complete an Incident Report.