Fraud, Waste, and Abuse (FWA)

Fraud, Waste, and Abuse (FWA)

Help us prevent fraud, waste, and abuse!

Community Health Choice has a team that works hard to identify and prevent fraud, waste, and abuse. If you see it, report it.

Ethics and Fraud Hotline

Fraud, Waste, and Abuse (FWA)

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law (42 C.F.R. § 455.2).

  • Example: Sam’s pharmacy bills for a prescription medication that Sam did not receive. The pharmacy knew Sam did not receive the medication, but the pharmacy billed for the medication anyway.

Waste means an overutilization of services or other 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.

  • Example: Rachel’s doctor consistently prescribes a high-priced medication for her. Her doctor is not aware of a generic alternative that is less expensive and available in the formulary.

Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program (42 C.F.R. §455.2).

  • Example: Jonathan went to his doctor to remove a wart on his finger. Jonathan’s doctor removed the wart then also obtained x-rays and performed a comprehensive physical examination that were unnecessary.

The Cost of FWA

The cost of FWA was more than $68 billion annually, according to the National Health Care Anti-Fraud Association (NHCAA). That cost affects both health plan members and health care providers.

  • Preventing you from getting medical services
  • Limiting your health care benefits
  • Raising your taxes
  • Keeping providers from being paid for services
  • Contributing to rising health care costs

The Crime of FWA

Healthcare fraud is a crime addressed by both state and federal laws.

For example, the federal Health Care Fraud Statute (18 U.S.C. § 1347) makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program, such as Medicaid. Health care fraud is punishable by imprisonment for up to 10 years. It is also subject to criminal fines of up to $250,000.

Protect yourself. Do not:

  1. Give your ID card or number to anyone other than your doctor, clinic, hospital, or other health care provider.
  2. Ask your doctor or any other health care provider for medical services or supplies that you don’t need.
  3. Sign your name to a blank form.
  4. Share your medical records with anyone other than your doctor, clinic, hospital or other health care provider.

Report FWA

Community Health Choice has a team that works hard to identify and prevent FWA, but we need your help.

  1. Document these things.
  • Who provided your health care
  • What services you received during the visit and any additional tests or visits the doctor ordered
  • When you got a health care service
  • Where the service was provided

Anonymously report fraud, waste, and abuse to Community Health Choice.

Phone:
FWA Hotline at 1.877.888.0002

Mail: 
Special Investigations Unit
2636 South Loop West, Suite 125
Houston, TX  77054

E-mail:
[email protected] 

Online:
Secure contact form

You may also report suspected fraud, waste, and abuse to the Texas Health and Human Services program.

Phone:
FWA Hotline at 1.800.436.6184

Online:
Inspector General – Report Fraud, Waste, and Abuse

General Information
Local: 713.295.2222
Toll-Free: 1.877.635.6736

Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m

Member Services
Local: 713.295.2294 | Toll-Free: 1.888.760.2600
Monday through Friday (excluding State-approved holidays) 8:00 a.m. to 6:00 p.m.

Provider Services Hotline
Call 713.295.2295, 8:00 a.m. - 5:00 p.m., Monday – Friday

Additional Contact Numbers

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law (42 C.F.R. § 455.2).

  • Example: Sam’s pharmacy bills for a prescription medication that Sam did not receive. The pharmacy knew Sam did not receive the medication, but the pharmacy billed for the medication anyway.

Waste means an overutilization of services or other 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.

  • Example: Rachel’s doctor consistently prescribes a high-priced medication for her. Her doctor is not aware of a generic alternative that is less expensive and available in the formulary.

Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program (42 C.F.R. §455.2).

  • Example: Johnathan went to his doctor to remove a wart on his finger. Jonathan’s doctor removed the wart then also obtained x-rays and performed a comprehensive physical examination that were unnecessary.

The Cost of FWA

The cost of FWA was more than $68 billion annually, according to the National Health Care Anti-Fraud Association (NHCAA). That cost affects both health plan members and health care providers.

  • Preventing you from getting medical services
  • Limiting your health care benefits
  • Raising your taxes
  • Keeping providers from being paid for services
  • Contributing to rising health care costs

The Crime of FWA

Healthcare fraud is a crime addressed by both state and federal laws.

For example, the federal Health Care Fraud Statute (18 U.S.C. § 1347) makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program, such as Medicaid. Health care fraud is punishable by imprisonment for up to 10 years. It is also subject to criminal fines of up to $250,000.

Protect yourself. Do not:

  1. Give your ID card or number to anyone other than your doctor, clinic, hospital, or other health care provider.
  2. Ask your doctor or any other health care provider for medical services or supplies that you don’t need.
  3. Sign your name to a blank form.
  4. Share your medical records with anyone other than your doctor, clinic, hospital or other health care provider.

Report FWA

Community Health Choice has a team that works hard to identify and prevent FWA, but we need your help.

  1. Document these things.
  • Who provided your health care
  • What services you received during the visit and any additional tests or visits the doctor ordered
  • When you got a health care service
  • Where the service was provided
  1. Anonymously report fraud, waste, and abuse to Community Health Choice.

Phone:
FWA Hotline at 1.877.888.0002

Mail: 
Special Investigations Unit
2636 South Loop West, Suite 125
Houston, TX  77054

E-mail:
[email protected] 

Online:
Secure contact form

You may also report suspected fraud, waste, and abuse to the Texas Health and Human Services program.

Phone:
FWA Hotline at 1.800.436.6184

Online:
Inspector General – Report Fraud, Waste, and Abuse