FRAUD, WASTE & ABUSE

Fraud, waste and abuse in health care cost billions of dollars each year. These improper activities can be committed by anyone who is giving or receiving health care services. Sometimes the activity is intentional. Other times it’s not on purpose and may involve being careless or not following the best medical practices.

We all need to be aware of what fraud, waste and abuse is and how to help prevent it. The goal is to ensure funds are available to support Medicaid and Medicare enrollees, and are not lost to fraud, waste, and abuse.

What Does Fraud, Waste and Abuse Look Like?

Some examples of who may commit health care fraud, waste and abuse include health care providers (e.g. physicians, hospitals, laboratories), members, or pharmacies. Examples of types of fraud, waste and abuse include the following.

Healthcare Providers who:

  • Order drugs, equipment, or services that are not medically necessary
  • Schedule more visits than are medically necessary
  • Bill for tests, services, or visits that you did not have
  • Bill for more expensive services than you received
  • Continue to bill for equipment or supplies you no longer need or use

Members who:

  • Share their AlohaCare member ID card with another person
  • Sell prescribed drugs or other medical equipment, paid for by AlohaCare, to others
  • Provide inaccurate symptoms and other information to health partners to get treatment or drugs
  • Do not report their correct income in order to qualify for Medicaid coverage

Pharmacies that:

  • Do not provide drugs according to the prescription
  • Give you a generic drug and send in a claim for a more expensive brand-name drug
  • Give you less than the prescribed drug amount without telling you and without giving you the rest of the amount you should receive

How Do I Report Suspect Fraud, Waste or Abuse?

If you think a provider or an AlohaCare member is committing fraud, waste or abuse, you can report your concerns to us by:

  • Calling Customer Service and reporting your concerns to a Customer Service Representative
  • Calling our Anonymous 24/7 Compliance hotline at 1-855-973-1852
  • Completing the Fraud, Waste and Abuse Reporting Form
  • Sending us a letter addressed to:
    AlohaCare
    Attn: Compliance - SIU
    1357 Kapi´olani Blvd
    STE G101
    Honolulu, HI 96814
    You do not have to give us your name when you write or call. There are other ways you may contact us that are not anonymous. If you are not concerned about giving your name, you may also use one of the following means to contact us by:
  • Email: fraud@alohacare.org
  • Fax: 1-808-973-7410

When you report fraud, waste or abuse, please give us detailed information that includes a clear description of what you believe has happened. Please also give us the names and phone numbers of those involved, if you have them. If you choose to remain anonymous, we will not be able to call you back for more information. Please leave as many details as possible. Your report will be kept confidential to the extent permitted by law.

How Can You Protect Yourself Against Fraud?

Below are a few simple tips to help protect you against health care fraud:

  • Treat your member ID card like you would a credit card. Don’t give out policy numbers to door-to-door salespeople, over the phone or on the internet. Watch out for people trying to offer you money or other free items for your personal information.
  • Beware of any offers for free services or items (food, gas, gift cards, etc.) in exchange for your AlohaCare member ID number.
  • Do not sign your name to a blank form. If you have questions about what you are signing, be sure to ask your health partner.
  • Read your Explanation of Benefit (EOB) statements and any papers you receive from AlohaCare. Are there any services, supplies or equipment listed that you did not receive? Are there any services that were billed more than once but you received only once? Did you get services on all the dates of service that are shown? If you suspect an error or fraud, report it to us using one of the methods above.

Mahalo for helping AlohaCare keep fraud, waste and abuse out of health care.