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What is Waste, Fraud and Abuse?

Waste, Fraud and Abuse in the Medicaid programs was a suspected problem soon after these programs were implemented and healthcare waste, fraud and abuse drives up healthcare costs. While we believe that most Providers and Members are honest we have to accept that some are not.

Waste refers to activities involving payment or the attempt to obtain payment for items or services where there was no intent to deceive or misrepresent but that the outcome of poor or inefficient methods results in unnecessary costs to the Medicaid/CHIP program.

Fraud is an intentional representation that an individual (Provider or Member) knows to be false or does not believe to be true and makes, knowing that the representation could result in some authorized benefit to himself/herself or some other person.

Abuse refers to activities that unjustly enrich a person through the receipt of benefit payments but where the intent to deceive is not present or the attempt by an individual to unjustly obtain a benefit for payment.

Why we investigate Waste, Fraud and Abuse:

The Texas Legislature and the Health and Human Services Commission (HHSC) have enacted new laws to fight waste, Fraud and Abuse in order to increase quality and efficiency in the Medicaid and CHIP programs and all Managed Care Organizations are required to develop a plan to prevent and reduce waste, fraud and abuse in these programs.

Examples of Waste, Fraud and Abuse:

• Filing claims for services or medications not received
• Forging or altering bills or receipts
• Using someone else's ID or Medicaid card
• Billing for services not actually performed
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary
• Misrepresenting procedures performed to obtain payment for services that are not covered
• Waiving patient co-pays or deductibles
• Over-billing the insurance carrier, benefit plan, or member
• Billing for a more expensive service than what was actually rendered (Upcoding)
• Billing more than once for the same service (Double billing)
• Using an inefficient or improperly trained coder whose inefficiency creates errors such as upcoding or double billing
• Neglecting to properly examine payments and as a result accepting payment for a Member that was not seen by your office

How to Report Fraud and Abuse
There are many ways to report waste, fraud and abuse. If you believe fraud has taken place call our Toll-free 24 hr hotline at 1-877-888-0002 or you may also call the Office of Inspector General (OIG) at 1-800-436-6184. These calls are anonymous and you do not need to leave your name or contact information. You can also submit your report online by clicking the link above.