Fraud and Abuse Concerns

Fraud is knowingly and willfully executing, or attempting to execute, a scheme to obtain financial or personal gain. (Example: billing for services not provided) The term does not include unintentional technical, clerical, or administrative errors.

Abuse is any action that may result in one or more of the following: unnecessary costs to the health care system, improper payment for services, payment for services that fail to meet professionally recognized standards of care and services that not medically necessary. (Example: billing excessive charges for services or supplies)

Fraud Protection and Prevention

FirstCare Health Plan’s Special Investigations Unit (SIU) utilizes fraud detection software for medical and prescription claims, investigates any suspicious claims and reviews concerns from members and other sources regarding possible fraud and abuse.

Common concerns from members are suspicious phone calls and bills for services not received.

Suspicious Phone Calls

Example: You receive a call from someone claiming to be from FirstCare Health Plan and they ask for personal information like your social security number or financial information.

If you suspect a call may be a scam, do not give any personal or financial information.

Here are a few ways you can protect yourself against future calls:

Bills for Services You Did Not Receive

Example: You see a service on your Explanation of Benefits (EOB) or get a bill for something you did not receive.

If you receive a bill for services you do not recognize, it is best to contact your provider first. It may be a simple error that can be easily corrected. If you still suspect fraudulent activity after speaking with your provider, you can contact the FirstCare Health Plan using one of the following:

FirstCare Health Plan Helpline
The helpline is a confidential means of reporting.

Phone: 1-866-399-8161
Web: FirstCare Health Plan Compliance Help Line




FirstCare Health Plan Compliance Officer

Phone: 1-214-820-8888
Mail:

FirstCare Health Plan
Compliance Department
12940 N. Hwy 183
Austin, TX 78750

Fax: 1-254-298-3508









You may also contact the Texas Department of Insurance (TDI) using one of the following:

 
Phone: 1-800-252-3439
Web:

Texas Department of Insurance - Report Fraud/File Complaint

Email: FraudReport@tdi.texas.gov
Mail MC 109-3A
Fraud Unit
Texas Department of Insurance
PO Box 149336
Austin, TX 78714-9336
Fax: 1-512-490-1001











Here are a few ways you can identify services billed to the Health Plan:
  • Review your monthly Health Plan Explanation of Benefits (EOB) to ensure accurate dates of service, name of providers, and services billed.
  • Use the MyBSWHealth app:  App Store and Google Play.

Potential Schemes Related to COVID-19

Scammers are using telemarketing, text messages, door-to-door visits as well as social media to conduct their fraudulent activities. These individuals are offering COVID-19 tests, grants and prescription cards in exchange for personal information to benefit themselves and harm the public.

Ways to protect yourself from fraud and abuse schemes:
  • Never share information to unknown individuals. This should include date of birth, social security number, Medicaid or Medicare numbers, health care details, financial or other personal identifiable information. Sharing this type of information can lead to identity theft.
  • Review your explanation of benefits (EOB) or MyBSWHealth for suspicious activity or claims.
  • Ignore offers or advertisements for COVID-19 testing or treatments on social media.
  • Never post photos of your COVID-19 vaccination cards on social media.
  • Do not open links in text messages from unknown individuals.
  • Do not trust any unexpected calls or visitors offering COVID-19 tests or supplies.
  • Do not pay anyone to speed up your vaccine eligibility.
  • Report suspected fraud to health plan helpline: 1-866-399-8161

Privacy Questions or Concerns?

Questions or concerns about your rights to privacy under HIPAA or Notice of Privacy Practices? Call the Compliance Helpline at 1-866-399-8161 or write to:
 
Compliance Officer
1206 West Campus Drive
Temple, TX 76502
1-214-820-8888

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