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Fraud, Waste & Abuse Prevention

At Simply Healthcare Plans (SHP), we have a zero-tolerance policy on Fraud, Waste and Abuse (FWA), and everyone is responsible to make a difference. The mission of the Plan’s Special Investigations Unit (SIU) 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.

As part of the overall Compliance and FWA program, the SIU maintains written policies and procedures and adheres to the Corporate Code of Conduct which articulates the organization's commitment to comply with all applicable Federal and State standards, including measures to detect, correct, and prevent FWA. SHP recognizes the importance of building the foundation of the Company FWA program around prevention versus post-payment recovery or a 'pay and chase' philosophy. SHP places great emphasis on leveraging real time data, technology and staff intervention at an earlier stage in the entire health care cycle to reduce vulnerability, lack of transparency and impact to FWA. This serves as the cornerstone of our ability to protect our beneficiaries and the overall integrity of the health care system as a whole.

Definitions and Examples

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.
 
Waste
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.
 
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.

  • Submit the Healthcare Fraud, Waste & Abuse Referral Form, which can be found here: https://www.simplyfwa.com/.

  • Email the SIU at SIU@simplyhealthcareplans.com.

  • Mail your concern to the following address: Special Investigations Unit, Simply Healthcare Plans, 9250 W. Flagler Street, Suite 600, Miami, Florida 33174-3460

You may also report to the following agencies:

To report suspected fraud 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 health care provider, you may be eligible for a reward through the Inspector General’s Fraud Rewards Program. You can call the Inspector General’s office at 850-414-3990 or toll free at 1-866-866-7226. The reward may be up to 25 percent of the amount recovered or a maximum of $500,000 per case (Florida Statutes Chapter 409.9203). You can talk to the Attorney General’s office about keeping your identity confidential and protected.

Florida Office of Financial Regulation, Division of Insurance Fraud: 1-800-378-0445

Department of Health and Human services, OIG Medicare Fraud Hotline: 1-800-HHS-TIPS

Whistleblower Protection: The Civil False Claims Act (31U.S. Code § 3729-3731) provides for protection for employees from retaliation. An employee who is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in terms and conditions of employment because of lawful acts done by the employee, contractor, agent or associated others in furtherance of an action under this Act may bring an action in the appropriate district court of the United States for relief, including reinstatement, back pay, or other compensation.

Last Updated: 
October 1, 2017