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Fraud, Waste & Abuse Prevention


At Simply Healthcare, we have a zero-tolerance policy on Fraud, Waste and Abuse (FWA), and everyone is responsible to make a difference. Our mission is to protect the overall integrity of the healthcare system, as well as to protect our members, providers, business partners and stakeholders by administering a comprehensive and effective anti-fraud plan to prevent, detect, investigate and resolve allegations of potential FWA.

What do we mean by Waste, Fraud and Abuse?

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.

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 his or her legal injury.

Abuse

Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid or Medicare 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 or Medicare program.

Other Terms Defined

Services Not Rendered Billing for goods and/or services that were never delivered or provided.

Not Medically Necessary Performing inappropriate or unnecessary medical procedures in order to increase payment.

Unbundling Using multiple billing codes instead of one billing code for a drug panel test in order to increase payment.

Up-coding Billing for a higher level of service than was actually provided.

Misrepresentation Forging a physician's signature to obtain pharmaceutical goods.

Double Billing Charging more than once for the same goods or services.  

Underutilization Not providing adequate medical care to increase profits.

Enrollment Fraud Enrolling a beneficiary into a health plan without that person's knowledge.

Theft of Services Utilizing someone else's insurance card to receive services; either through stealing the card or having it provided by the true card holder.

Overpayment  Overpayment defined in accordance with s. 409.913, F.S., includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.

Reporting Health Care Fraud, Waste & Abuse

If you have a reason to believe Fraud, Waste or Abuse (FWA) may have been committed, please contact us immediately and together we can make a difference. Call the Confidential Compliance and Fraud, Waste & Abuse Hotline at 1-877-253-9251. Email us at SIU@simplyhealthcareplans.com.

Last Updated: August 1, 2018