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Reporting Suspected Fraud, Waste & Abuse

 

Fraud, Waste and Abuse Tipline: 1-877-972-8844

Our Commitment is to protect our consumers and their families, providers, business partners, employees and stakeholders by administering a strong and effective anti-Fraud, Waste and Abuse (FWA) program designed to prevent, detect, investigate and resolve incidents of potential FWA.

The Impact of Fraud, Waste and Abuse on Our Health Care System

The National Health Care Anti-fraud Association (NHCAA) estimates that between 3% and 10% of health care spending is lost due to fraud, waste and abuse (FWA). Using those figures, we are losing between $70 Billion and $260 Billion each year due to FWA.

How is Fraud, Waste and Abuse (FWA) defined?

  • Fraud: Intentional misrepresentation to gain a benefit.
  • Waste: Any unnecessary consumption of health care resources.
  • Abuse:Unsound business practices that result in undue remuneration.

What are some examples of FWA?

  • Billing for Services Not Rendered
  • Billing Using a Different Provider’s ID Number/TIN/NPI
  • Over Utilization of Services or Providing Services not Medically Necessary
  • Unbundling Services to Maximize Revenue
  • Non-Licensed Professionals Providing Services
  • Billing for Member Cancellations and No-Shows
  • Falsifying Clinical Notes/Forgery
  • Billing for Excessive Numbers of Patients in One Day
  • Office Associates Defrauding the Provider
  • Theft of ID/Services
  • Pharmacy/Doctor Shopping
  • Member Kickback

What should I do if I suspect FWA?

Anytime there is a suspicion of Fraud, Waste or Abuse, please report it immediately. The faster we know about it, the faster we can intervene.

How do I contact Optum’s Program and Network Integrity Department?

Communications are confidential and you may choose to be anonymous.

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