Learn more about Fraud, Waste & Abuse

 

As part of our continued efforts to improve the quality of the healthcare services provided to our members, Doctors HealthCare Plans, Inc. (DHCP) has made a commitment to detect, prevent and deter Fraud, Waste and Abuse (FWA). 

What is Fraud, Waste & Abuse?
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain any of the money or property owned by, or under the custody or control of, any healthcare benefit program.

Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.

Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowing and/or intentionally misrepresented facts to obtain payment.

How to Report Fraud, Waste & Abuse

If you suspect fraud, waste or abuse, please report it to us and it will be investigated by the Special Investigation Unit.

To report suspected fraud, waste or abuse, you can contact us by: 

• Phone: English / Spanish: (833) DHCP 911 or (833) 342 7911
• Fax: (786) 628 2600
• E-mail
• Mail: Doctors HealthCare Plans, Inc., Attn: Special Investigation Unit, 2020 Ponce de Leon, Blvd, PH 1, Coral Gables, FL 33134

You have the option to remain anonymous. All information received by the Special Investigations Unit (SIU) will be treated as confidential, and reporting if needed to state and federal authorities.

Help in the fight against Fraud, Waste & Abuse
Doctors HealthCare Plans, Inc. strives to maintain its employees, providers, vendors and members alert and informed on the fight against fraud, waste and abuse. We have developed a Code of Conduct, a Provider Manual, Policies and Procedures and other documents to assist in the fight.

For more information on preventing, detecting, and reporting fraud and abuse, as well as other Medicare and Medicaid information, refer to the resources listed below:

Resource	Website
Protect yourself from Fraud	https://www.doctorshcp.com/protect-yourself-from-fraud/
CMS Fraud and Abuse Educational Products	MLN Publications | CMS
CMS Fraud Prevention Toolkit	https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/FraudPreventionToolkit.html
CMS National Training Program Resources	https://cmsnationaltrainingprogram.cms.gov/resources
Can Someone Change my CPT Codes?	https://www.medscape.com/viewarticle/872465 Note: To access this article, you need to create a free account.
Center for Program Integrity: Protecting the Medicare & Medicaid Programs from Fraud, Waste, & Abuse	https://www.cms.gov/About-CMS/Components/CPI/CPI-Landing.html
Help Fight Medicare Fraud	https://www.medicare.gov/forms-help-resources/help-fight-medicare-fraud
How to Report Medicare Fraud	https://www.medicare.gov/forms-help-resources/help-fight-medicare-fraud/how-report-medicare-fraud
How to Report Medicaid Fraud	https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforConsumers/Report_Fraud_and_Suspected_Fraud.html
Medicaid Program Integrity Education	https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/edmic-landing.html
MLN Provider Compliance	https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html
OIG Advisory Opinions	https://oig.hhs.gov/compliance/compliance-resource-portal/
OIG Compliance 101	https://oig.hhs.gov/compliance/compliance-resource-portal/
OIG Contact Information	https://oig.hhs.gov/contact-us/
OIG Fraud Information	https://oig.hhs.gov/fraud/
Physician Self-Referral	https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/
Learn how to identify what Medicare considers fraud & abuse, provisions & penalties, prevention methods, and recognize how to report fraud & abuse.	https://www.cms.gov/Outreach-and-education/MLN/WBT/MedicareFraudandAbuse/FraudandAbuse/story.html

 

 

 

 

H4140_FWA_C
Last Updated:  06/05/2023