Defining Fraud and Abuse
Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to them or some other person.
Abuse means provider practices that are poor business or medical practices, and/or result in an unnecessary cost to your benefit program. This can include reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes member behaviors that may result in unnecessary cost to the program.
We investigate cases of suspected fraud and abuse through a comprehensive review process. All findings are submitted for further investigation, determination, and action to state regulators and law enforcement agencies as required.