Fraud, Waste and Abuse (FWA)

What is Fraud, Waste and Abuse (FWA)?

• Fraud: 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 money or property owned by, or under the custody or control of, any health care benefit program. Fraud occurs when an individual knows or should know that something is false and makes a knowing deception that could result in some unauthorized benefit to themselves or another person.
• Waste: Over-utilization of services (not caused by criminally negligent actions) and the misuse of resources.
• Abuse: Includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. 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.

Acts of fraud can be committed by any person or entity, including insurance companies, beneficiaries, providers (physicians, labs, suppliers), pharmacies, or agents. Violations of the code of conduct, ethics, or any fraud, waste, or abuse must be reported. Everyone has the right and responsibility to report compliance issues and possible fraud, waste, or abuse. Not reporting fraud or suspected fraud can make you a party to a case by allowing the fraud to continue. You can report suspected FWA to the Health Plan's Compliance team directly; or if you wish to report anonymously you can call the Corporate Compliance and Ethics Hotline at the number listed below:

• (713) 338-4140 or 1 (877) 448-4140
• Para ayuda en español: 1 (800) 297-8592

For more information, you can also email the Compliance-FWA department at MHHealthPlanFWA@memorialhermann.org

For Providers

Fraud, Waste and Abuse (FWA)

Most doctors work ethically, providing high-quality medical care, and ensuring the submittal of proper claims for payment.

Federal and state governments place a great amount of trust in physicians. Medicare, Medicaid and other government health care programs rely on physicians’ medical judgment to treat patients with appropriate services. When reimbursing physicians, hospitals, labs, and durable medical equipment suppliers for services provided to program patients, the federal government relies on physicians to submit accurate and truthful information.

Unfortunately, dishonest providers who exploit the health care system for illegal personal gain have created the need for laws that combat fraud and abuse and that ensure appropriate quality medical care. Some of those laws are listed below:

• Anti-Kickback Statute (42 USC § 1320a-7b(b))
• Stark Law (42 USC § 1395nn)
• Federal False Claims Act 31 (U.S.C. §§ 3729 – 3733)

The Centers for Medicare and Medicaid Services (CMS) helps physicians understand how to comply with federal laws by identifying "red flags" that could lead to potential liability in law enforcement and administrative actions. For more information, read Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians.

Protecting your medical practice against health care fraud is important too. CMS provides training on safeguarding your medical identity.