The definition of Fraud is the intentional deception or misrepresentation that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s).

The definition of Waste is the unintentional misuse of Medicare funds through inadvertent error, most frequently incorrect coding and billing.

The definition of Abuse is the reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. Practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the health plan.

Types of FWA

• Claim FWA: Alteration of claims, Up-coding, Incorrect coding, Double billing, Unbundling, Billing for services not provided, Submission of false documents, Billing non-covered services as covered
• Member FWA; Identity theft, Prescription altering, Doctor shopping, Prescription stockpiling, Misrepresentation of eligibility or medical condition

FWA Laws

• False Claims Act – 31 U.S.C. 3729-3733
• Anti-Kickback Statute – 41 U.S.C.
• HIPAA – 45 CFR Title II, 201-250
• Deficit Reduction Act – Public Law 109-171,6032
• Whistleblower Employee Protection Act – 31 U.S.C. 3730(h)
• Stark Law – Social Security Act 1877

Non-Retaliation

Subcontractors are protected from retaliation under 31 U.S.C. 3730(h) for False Claims Act complaints. Health Choice encourages the reporting of suspected FWA confidentially and without fear of retaliation. Zero-tolerance policy for retaliation or retribution against anyone who reports suspected misconduct

Penalties for FWA

It is a federal crime to defraud the government of any of its programs. Individuals who commit fraud may be imprisoned, fined, or both. Criminal convictions typically include restitution and fines. Convictions may also result in being excluded from the Medicare program for a length of time.

Reporting Suspicious Activity

• Report suspicious or potential FWA to BCBSAZ Health Choice Pathway through your Provider Services Representative
• Call the Health Choice Compliance Alert Line at 1-800-237-0916, TTY 711, 24 hours a day, 7 days a week
• Email Health Choice Compliance at : HCHFWA@azblue.com
• Include all information that supports the potential misconduct

For more information on reporting FWA:
Subcontractor Reporting Guide