Understanding Healthcare Fraud, Waste, and Abuse
Healthcare fraud, waste, and abuse (FWA) is a national issue which even impacts Group Health Cooperative of South Central Wisconsin (GHC-SCW). We seek to uphold the highest ethical standards when providing care and services to our members. However, preventing FWA is an organizational effort which requires every employee, member, insurance agent, and provider to be knowledgeable about what FWA involves and looks like.
If you are questioning if something is FWA, please report it! By submitting a FWA report GHC-SCW will investigate the situation to determine if FWA has occurred. If it is an error that occurred because of our mistake, or a mistake by another entity, the FWA team will connect you with the GHC-SCW Member Services Department to resolve the issue.
What is Fraud?
Fraud is defined as 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.
What is Waste?
Waste is defined as expenditure, consumption, mismanagement, use of resources, practice of inefficient or ineffective procedures, systems, and/or controls to the detriment or potential detriment of entities. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
What is Abuse?
Abuse is defined as actions that may, directly or indirectly, result in: unnecessary costs, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
What does FWA look like?
|Examples of FWA by a Provider/Facility||Examples of FWA by a Member/Patient|
|Falsifying codes, records, or altering claims||Using someone else’s insurance card|
|Billing for services not rendered or goods not provided||Forging a prescription|
|Billing separately for services that should be a single service||Knowingly enrolling someone not eligible for coverage under their policy or group coverage|
|Billing for services not medically necessary||Providing misleading information on or omitting information from an application for health care coverage, or intentionally giving incorrect information to receive benefits|
|Over-utilization: Medically unnecessary diagnostics, unnecessary durable medical equipment, unauthorized services, inappropriate procedures or diagnosis||Altering the billed amount for services. Altering the service date of services.|
Fraud, Waste, and Abuse Frequently Asked Questions
The investigation will vary depending on the situation and allegation. An investigation generally follows these steps:
1. A GHC-SCW FWA team member will contact relevant parties to gather information. The goal of information gathering is to get a better understanding of the situation. We may ask questions like, how long was the visit, describe the services provided, and who provided the care. If you choose to remain anonymous in your report, we ask that you provide as much information as possible without revealing your identity.
2. As appropriate, GHC-SCW will make requests for medical records. These medical records are used to validate the services billed.
3. In cases where there is a credible allegation of fraud, waste, or abuse GHC-SCW will notify all applicable state and/or federal agencies regarding the case.