Report Fraud, Waste and Abuse

As part of our efforts to improve the healthcare system, PA Health & Wellness has made a commitment to detecting, correcting, and preventing fraud, waste, and abuse.

Success in this effort is essential to maintaining a healthcare system that is affordable for everyone.

Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice 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. (18 U.S.C. ยง 1347)

Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Abuse includes any action(s) that may, directly or indirectly, result in one or more of the following:

  • Unnecessary costs to the healthcare system, including the Medicare and Medicaid programs
  • Improper payment for services
  • Payment for services that fail to meet professionally recognized standards of care
  • Services that are medically unnecessary

If you suspect fraud, waste, or abuse in the healthcare system, you must report it to PA Health & Wellness and we'll investigate. Your actions may help to improve the healthcare system and reduce costs for our participants, customers, and business partners.

To report suspected fraud, waste, or abuse, you can contact PA Health & Wellness in one of these ways:

You may remain anonymous if you prefer. All information received or discovered by the Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, corporate law department, market medical directors or senior management).

Our investigation process will vary, depending on the situation and allegation. Our investigational steps may include the following:

  • Contact with relevant parties to gather information. This may include contacting participants to get a better understanding of the situation. For example, we may contact a participant to ask about a visit with his or her physician. We may ask the participant to describe the services provided, who provided the care, how long the member was at the office, etc.
  • Requests for medical or dental records. We do this to validate that the records support the medical or dental services billed. It's important that the health care provider submits complete records as requested. We rely on this information to make a fair and appropriate decision.

Notification of suspected fraud and abuse to law enforcement and CMS, if applicable, including the appropriate Medicare Drug Integrity Contractor (MEDIC) for Medicare part C (medical) and part D (prescriptions) and any other applicable state and/or federal agencies.

Some of the most common coding and billing issues are:

  • Billing for services not rendered
  • Billing for services at a frequency that indicates the provider is an outlier as compared with their peers.
  • Billing for non-covered services using an incorrect CPT, HCPCS and/or Diagnosis code in order to have services covered
  • Billing for services that are actually performed by another provider
  • Up-coding
  • Modifier misuse, for example modifiers 25 and 59
  • Unbundling
  • Billing for more units than rendered
  • Lack of documentation in the records to support the services billed
  • Services performed by an unlicensed provider but billed under a licensed providers name
  • Alteration of records to get services covered