Fraud, Waste and Abuse
Commonwealth Care Alliance is committed to its members, providers and employees to actively prevent, identify, investigate, mitigate and report any suspected cases of fraud, waste and/or abuse
What is fraud, waste and abuse?
Fraud is defined as knowingly and willfully executing, or attempting to execute, a scheme to defraud any healthcare 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 healthcare benefit program.
Waste is defined as the unintentional, thoughtless or careless expenditures, consumption, mismanagement, use or squandering of Commonwealth Care Alliance, federal or state resources.
Abuse is defined as practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to government programs or in reimbursement for services not medically necessary or that fail to meet professionally recognized standards for healthcare.
Examples of potentially fraudulent, wasteful, and abusive practices
- Billing for services not provided
- Inaccurate billing of services
- Individuals who use someone else’s identification card
- Changing the dates of service to gain payment
- Delivery of durable medical equipment supplies to a member when not prescribed/ordered
To report suspected fraud, waste, or abuse to Commonwealth Care Alliance:
Call Commonwealth Care Alliance’s anonymous Compliance Hotline at 1-800-826-6762 or contact Commonwealth Care Alliance’s Regulatory Affairs and Compliance Department at 1-617-426-0600 or via firstname.lastname@example.org
Last Updated 07/29/2013