Identifying Fraud, Waste and Abuse (FWA)

FirstCare's Special Investigations Unit (SIU)

By helping us identify healthcare FWA, you help avoid reduced benefits, higher taxes, increased premiums, and more expensive doctor visits and prescriptions.

REPORT suspected FWA here 
 
By clicking the above link I acknowledge that I have read and understand the following advisory:
Please be advised, any information provided in the FirstCare Incident Report Form will become part of an investigation which may be shared with federal or state government agencies. Generally, information received by FirstCare's Special Investigations Unit is considered confidential and will not be disclosed unless otherwise required by law.

Join forces with FirstCare's SIU to investigate health care fraud and compliance incidents perpetrated by either a FirstCare member, FirstCare provider, and /or other party.
 
Know that FirstCare will work jointly with various state and federal agencies to prosecute health care FWA, including the Federal Bureau of Investigation (FBI), Internal Revenue Service (IRS), United States Health and Human Services Division - Office of Inspector General (OIG), Texas Attorney General's Office, Texas Health and Human Services Commission - Office of Inspector General, and local law enforcement authorities.
 
Information given on this FirstCare Incident Report Form will become part of an investigation which may be shared with federal or state government agencies. Generally, information received by FirstCare's Special Investigations Unit will be kept confidential unless required by law.

Other FWA reporting options:
  • Call FirstCare's Anonymous FWA Hotline: 1-800-718-5205
  • Write a FWA complaint. Mail to:
FirstCare Health Plans
Compliance Department
Attn:  SIU Investigator
12940 N Highway 183
Austin, Texas 78750

What is Fraud, Waste and Abuse?

Fraud is any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or some other person. The term does not include unintentional technical, clerical, or administrative errors.  
 
Waste involves practices that a reasonably prudent person would deem careless or that would allow inefficient use of resources, items, or services.
 
Abuse involves practices that are inconsistent with sound fiscal or business practices and that result in unnecessary costs.

Provider Fraud, Waste and Abuse
Please tell us if you suspect a provider of the following:

  • Billing for services or items that were never provided
  • Billing separate claims for services that should be billed together as a single item
  • Billing for services or equipment that are more expensive than what was supplied
  • Continuing to bill for home medical equipment after it has been returned
  • Scheduling unnecessary office visits, x-rays, laboratory or other services
  • Taking payment from another provider in exchange for referring a patient
  • Allowing an unlicensed person to perform treatment and billing as if a qualified individual had performed the service.

Recipient Fraud, Waste and Abuse
Individuals may try to game the system to receive money and/or benefits they don't deserve.  It is a crime to commit insurance fraud, and people can lose their benefits and be prosecuted.


Please tell us if you witness recipient activities like:
  • Loaning a Medicaid Identification or other insurance card to another person
  • Using someone else's Medicaid Identification or other insurance card
  • Forging or altering a prescription
  • Doctor shopping in order to obtain multiple prescriptions
  • Using multiple Medicaid Identification cards
  • Intentionally receiving unneeded services or supplies
  • Accepting cash or other bribes for receiving services
  • Re-selling items provided by the Medicaid program
  • Deliberately giving incorrect information to receive benefits

Detecting and Preventing Fraud, Waste and Abuse

Want to help uncover and stop wrongful billing practices? Keep a record of your medical treatment.
 
Write down:
  • The date you received medical care
  • Where the service took place
  • What services were provided to you
  • The names of who provided the services
  • What tests or additional services were ordered by the providers
You should be suspicious if the provider tells you that:
  • The test is free; he only needs your insurance number for his records
  • They know how to get your insurance to pay for it
  • The more tests they provide the cheaper they are
  • The equipment or service is free; it won't cost you anything
  • Advertise "free" consultations in exchange for your insurance information
  • Use telemarketing and door-to-door selling as marketing tools.
To help prevent FWA, report your suspicions.  Review your Explanation of Benefits or payment notice for errors.  Make sure you were not billed for health care services, medical supplies or equipment you did not receive.

Other entities to contact for suspected FWA:

Privacy Questions or Concerns?

Questions or concerns about your rights to privacy under HIPAA or NOPP? Call the FirstCare Compliance Hotline at 1.866.399.8161 or write to:
 
FirstCare Health Plans
Attn: Privacy Officer
12940 N. Hwy 183
Austin, TX 78750

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