Report fraud, waste, or abuse

Health care fraud is a crime addressed by both state and federal laws. For example, the federal Health Care Fraud Statute (18 U.S.C. § 1347) makes it a criminal offense to knowingly and willfully execute a scheme to defraud a health care benefit program, such as Medicaid. Health care fraud is punishable by imprisonment for up to 10 years. It is also subject to criminal fines of up to $250,000.

The cost of fraud, waste, and abuse (FWA) was more than $3 trillion in 2014, according to the National Health Care Anti-Fraud Association (NHCAA). You can anonymously report fraud to Select Health of South Carolina with the secure contact form.

You may also report suspected fraud, waste, and abuse to South Carolina’s Division of Program Integrity.

• Call: Fraud and Abuse Hotline at 1-888-364-3224.
• Email: fraudres@scdhhs.gov.
• Mail: SC FRAUD HOTLINE, Division of Program Integrity
  1801 Main Street, P.O. Box 100210, Columbia, SC 29202-3210

Why should I care about fraud, waste, and abuse?

Fraud, waste, and abuse (FWA) affect both health plan members and health care providers. FWA can:

• Prevent you from getting medical services.
• Limit your health care benefits.
• Raise your taxes.
• Keep providers from being paid for services.
• Contribute to rising health care costs.

In addition, health care fraud is a real crime with real consequences. It could lead to fines or even jail time.

What are fraud, waste, and abuse?

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law (42 C.F.R. § 455.2).

• Example: Sam’s pharmacy bills Medicaid for a prescription medication that Sam did not receive, and the pharmacy knew Sam did not receive the medication, but the pharmacy billed for the medication anyway.

Waste is an overutilization of services, or other practices that directly or indirectly result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.

• Example: Rachel’s doctor (unaware of the generic alternative) consistently prescribes a high-priced medication for her instead of the less expensive drug available in the formulary.

Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program (42 C.F.R. §455.2).

• Example: Jonathan’s doctor obtained x-rays and blood tests and performed a comprehensive physical examination of Jonathan when Jonathan only wanted to see the doctor to remove a wart on his finger.

Remember: Report health care fraud to the Select Health of South Carolina Fraud Tip Hotline at 1-866-833-9718.