Scott & White Health Plan

Fraud, Waste and Abuse

Did you know that healthcare fraud costs Americans billions each year?  Here at Scott & White Health Plan we are dedicated to protecting you against fraudulent conduct.  There are many ways in which you can help us fight healthcare fraud. 
 
What is Medicare Fraud?
Fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person¹.  Some examples of Medicare fraud are:

• Billing Medicare for services or items you never received;
• Billing Medicare for services or equipment which are different from what you received. 
• Use of another person's Medicare card to get medical care, supplies, or equipment.
• Billing Medicare for home medical equipment after it has been returned.

How Can I Be Proactive in Preventing Fraud?
Because Medicare fraud costs the Medicare program millions of dollars annually, people with Medicare pay for it with higher premiums. You can help prevent, avoid and detect fraud by following some simple steps:  

• Review your monthly Scott & White Health Plan Explanation of Benefits (EOB) and ensure that you received all services stated on the document.  The EOB is a listing of medications that you received, the copayment that you paid, and the amount that was billed to your insurance for the previous month;
• Review your Medicare Summary Notice (MSN) and ensure that you received all services stated on the document.  The MSN shows what Medicare was billed for, what Medicare paid and what you owe;
• Don't ever give out your Medicare Health Insurance Claim Number (on your Medicare card) except to your physician or other Medicare provider.
• Do be cautious when you are offered free testing or screening in exchange for your Medicare card number.

What if I Suspect Fraud?
If you find a suspicious charge on your EOB or MSN, call your provider first. It could be a simple error that can be easily corrected. If you still suspect fraud after speaking with them, you can contact Scott & White Health Plan Hotline or contact the Office of the Inspector General Hotline. The hotlines offer a confidential means of reporting information.

If you have specific information proving Medicare fraud, please provide as much identifying information as possible regarding your concern. Such information should include subject's name, address and phone number. Details regarding the allegation should include the basics of who, what, when, where, why, and how.  

How is Scott & White Health Plan Working to Minimize Fraud?
Scott & White Health Plan’s Special Investigative Unit (SIU) and auditors utilize fraud detection software for medical and prescription claims, investigate any suspicious claims and follow necessary actions.

For additional information on how to protect Medicare and you from fraud, please visit the Medicare website and read, "Protecting Medicare and You From Fraud."

¹ - Department of Health and Human Services

The above information is current as of October 2010.

"Medicare-Approved HMO"

H4564_SC_WEB_FRAUD_2011_REV_122010  CMS Approved 02/08/2011