Commonwealth Care Alliance

Senior Care Options Program (HMO SNP)

For Providers » Compliance and Fraud, Waste & Abuse Program » Examples of Healthcare Fraud, Waste & Abuse

Examples of Healthcare Fraud, Waste & Abuse

By Members

  • Someone uses another person’s Medicare card to receive medical care, supplies, or equipment
  • A member agrees to let a healthcare provider bill Medicare for services they did not receive
  • Member does not disclose other health insurance coverage
  • Member misrepresents medical condition to obtain services
  • Member provides false information on enrollment form

By Providers

  • Unnecessary care
  • Incorrect coding/billing practices
  • Fraudulent diagnoses
  • Billing for services not rendered
  • Kickbacks/solicitations

By Employees

  • False claims address or PO box
  • Selling members’ or providers’ identification
  • Misrepresenting facts in order to deny or grant benefits
  • Obtaining kickbacks or referrals

Sales and Marketing

  • Forging members’ signatures for enrollment purposes
  • Advising beneficiaries to enroll in a plan that is unnecessary or unwanted
  • Misrepresenting benefits
  • Impersonating a government employee

By Pharmacies

  • Inappropriate billing practices
    • Billing multiple payors for the same prescription
    • Billing for non-existent prescriptions
    • Billing for brand when generics are dispensed
    • Billing for an item not dispensed
    • Prescription splitting to receive additional dispensing fees
  • Prescription drug shorting
  • Bait and switch pricing
  • Prescription forging or altering
  • Dispensing expired prescription drugs
  • Prescription refill errors
  • Failure to offer negotiated prices

Coding

  • Upcoding (using codes that pay at a higher rate)
  • Bundling/unbundling of claims
  • Routinely submitting duplicate claims

Last Updated 07/29/2013