Fraud, Waste, and Abuse
CoxHealth Medicare Advantage
Reporting suspected Fraud, Waste, and Abuse is a vital way you can help to protect yourself and others. Reporting a concern may help uncover more widespread fraud, waste, and abuse and also prevent personal loss. It is also a valuable way to save health care dollars for everyone. After you file a report, Cox HealthPlans works to detect, correct, and prevent fraud, waste, and abuse. You can report a concern anonymously by filling out the form below, by calling the Compliance Hotline (417)269-2814, or by sending an email to ComplianceSIU@coxhealthplans.com.
How to recognize Fraud, Waste, or Abuse
- Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program. 18 U.S.C. § 1347.
- Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to a health care benefit program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.
- Abuse includes actions that may, directly or indirectly, result in unnecessary costs to a healthcare benefit program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.
Examples:
A provider submitting claims for treatment that were never provided.
A pharmacy intentionally providing less than the prescribed quantity and the member is not informed.
A member seeing multiple providers in an attempt to receive multiple prescriptions.
How you can protect yourself
- Guard your health insurance card
- Do not give out any personal or health insurance information
