You can help prevent health care fraud. 

The National Health Care Anti-Fraud Association estimates that the financial losses from health care fraud are about $100 million per day.

Community Health Plan of Washington is committed to doing all we can to prevent, detect, and correct health care fraud.

When you report a situation that may be potential health care fraud, you’re doing your part to help save money for the health care system.

What is health care fraud, waste, and abuse?

Fraud occurs when someone knowingly and willfully submits a false claim that results in inappropriate payments.

Waste is overuse of services or other practices that, directly or indirectly, results in unnecessary medical costs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Abuse is an action that may result in unnecessary medical costs. It’s when a person or entity has not knowingly and/or purposely misrepresented facts to obtain payment.

Examples of Fraud, Waste, and Abuse

Fraud

  • Billing for services not rendered.
  • Falsifying a patient's diagnosis to justify  unnecessary procedures.
  • Accepting kickbacks for patient referrals.

Waste

  • Ordering excessive diagnostic tests.
  • Overuse of office visits.
  • A pharmacy sending medications to members without confirming they still needs them.

Abuse

  • Charging in excess for services or supplies.
  • Providing medically unnecessary services.
  • Going to different doctors or emergency rooms to obtain pain medication. 

 

 

 

 

 

 

 

If you still have questions about health care fraud, waste, or abuse, please read our Frequently Asked Questions page or refer to the resources below:

Report potential fraud

You can submit a Potential Fraud Report to CHPW via email, fax, or mail using contact information on the form.

You can also call the Compliance Hotline and report potential fraud anonymously: 1-800-826-6762