Fraud, Waste, and Abuse - Washington State Local Health Insurance - CHPW

Fraud, Waste, and Abuse

The cost of fraud

The National Health Care Anti-Fraud Association estimates that financial losses from health care fraud are about $100 million per day. Fraud, waste, and abuse take money away from health care programs and make it harder to pay for needed care. It’s also tied to increasing care costs.

At Community Health Plan of Washington (CHPW), we’re dedicated to stopping health care fraud, waste, and abuse. Here’s how to spot it and how you can help.

What are fraud, waste, and abuse?

Fraud

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

Examples of fraud:

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

Waste

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.

Examples of waste:

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

Abuse

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

Examples of abuse:

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

How CHPW fights fraud

CHPW has developed a comprehensive training program for our providers, which they can access to learn how to prevent, spot, and report fraud.

We also provide an easy online tool where our members can report possible fraud, waste, or abuse.

Report Online

Protecting yourself from fraud, waste, and abuse

Follow these easy tips to help stop fraud:

  • Give your Community Health Plan of Washington ID card or ID number only to a health care provider, clinic, or hospital.
  • Give your ID only when you are getting care.
  • Never let anyone borrow your Community Health Plan of Washington ID card.
  • Never sign a blank insurance form.
  • Always be ready to show picture ID when checking in for a medical appointment.
  • Be careful about giving out your Social Security number.

Report potential fraud

When you report a situation that may be fraud, you’re doing your part to improve the health care system. If you suspect fraud, waste, or abuse, you can report it to us online:

Report Online

Or via email, mail, or fax:

Potential Fraud Report

If you still have questions about health care fraud, see the resources below:

DID YOU KNOW...?

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