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Fraud/Waste/Abuse

Help Us Stop Fraud, Waste and Abuse

Simply Healthcare Plans wants you to get the Respect You Deserve and the Service You Expect. When fraud and abuse happens, it hurts you, your doctors and everyone in the health care system.

Fraud - A false representation of a matter of fact - whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed - that deceives and is intended to deceive another so that the individual will act upon it to her or his legal injury. 

Waste - An attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, but the outcome of a billing error caused unnecessary costs to the involved companies. Waste includes overutilization of services not caused by criminally negligent actions. Waste also involves the misuse of resources.

Abuse – Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the Medicaid program.

Things You Can Do to Stop Fraud, Waste and Abuse:

  • Never let anyone use your Member ID number.
  • Do not share your medical records with anyone except your doctor, hospital or health plan.
  • Never ask your doctor for medical services or drugs you do not need.
  • If someone offers you free tests or services using your Member ID card, beware! If you think it sounds too good to be true, you are probably right. Call Member Services at 1-800-887-6888 for help. 

Remember, fraud is against the law. One way to stop it is to report it.

To report suspected fraud, waste or abuse to the Plan call the Plan’s Confidential Compliance and Fraud, Waste & Abuse Hotline at 1-877-253-9251, send an email to SIU@simplyhealthcareplans.com or fill out and submit the online FWA Referral Form.

To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx.

If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other healthcare provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to twenty-five percent (25%) of the amount recovered or a maximum of $500,000 per case (Section 409.9203, Florida Statutes). You can talk to the Attorney General’s Office about keeping your identity confidential and protected.