Fraud, Waste & Abuse

Health care fraud, waste and abuse hurts everyone including members, providers, taxpayers and CareSource. As a result, CareSource has a comprehensive fraud, waste and abuse program in our Program Integrity department. Please help us by reporting questionable activities and potential fraud, waste and abuse situations.

Provider Fraud, Waste & Abuse

Below are some examples of provider activity that is monitored for fraud, waste and abuse:

• Prescribing drugs, equipment or services that are not medically necessary
• Billing more than once for the same service
• Intentionally using improper medical coding to receive a higher rate of reimbursement
• Billing for services not provided
• Scheduling more frequent return visits than are needed
• Unbundling services to obtain higher reimbursement
• Purchasing drugs from outside the United States
• Prescribing high quantities of controlled substances without medical necessity

Member Fraud, Waste & Abuse

CareSource monitors member activity for fraud, waste and abuse. Some examples are:

• Inappropriately using services such as selling prescribed narcotics, or seeking controlled substances from multiple providers or multiple pharmacies
• Sharing a member ID card
• Obtaining unnecessary equipment/supplies
• Changing prescription forms to get more than the amount of medication prescribed by their physician
• Member receiving services or picking up prescriptions under another person’s ID (identity theft)

Pharmacy Fraud, Waste & Abuse

Some examples of pharmacy fraud, waste and abuse are:

• • Prescription drugs not dispensed as written
  • Submitting claims for a more expensive brand name drug when a less expensive generic prescription is dispensed
  • Dispensing less than the prescribed quantity without arranging for the additional medication to be received with no additional dispensing fees

• Splitting prescriptions into two orders to seek higher reimbursement
• Dispensing expired, fake, diluted or illegal drugs
• Billing for prescriptions not filled or picked up

Employee Ethics

It is also important for you to tell us if a CareSource employee acts inappropriately. Some examples are:

• Receiving gifts or kickbacks from vendors for goods or services purchased by CareSource
• Inappropriately marketing our company to potential members
• Behaving in an unethical or dishonest manner while performing company business

Corrective action of any identified fraud, waste and/or abuse are available in the provider manual. For provider terminations/suspensions information, the CareSource Fair Hearing Plan is available on this website.

Report Fraud, Waste & Abuse

Please give a detailed description of the activity, including the:

• Provider/member/employee name
• Provider/member number, if available
• Date of activity
• Issue of concern
• All other pertinent information

Your report may be anonymous; however, if you do not provide your name, we will not be able to call you back for more information. Your message will be kept confidential to the extent permitted by law.

Thank you for your assistance in keeping fraud, waste and abuse out of health care.

CareSource is required to provide you with information on the False Claims Act, please see details below.

False Claims Act

Visit False Claims Act for more information.

Prohibited Affiliations / 42 C.F.R. § 438.610

CareSource is prohibited by federal and/or state provider agreements from knowingly having relationships with persons who are debarred, suspended or otherwise excluded from participating in federal procurement and non-procurement activities. Relationships must be terminated with any trustee, officer, employee, provider or vendor who is identified to be debarred, suspended or otherwise excluded from participation in federal or state health care programs. If you or your office management employees are excluded, you must notify us immediately.

From the Office of the Inspector General

The Office of the Inspector General (OIG) has created free educational materials to assist in teaching physicians about the federal laws designed to protect Medicaid, Medicare and Marketplace programs and program beneficiaries from fraud, waste and abuse.