Fraud, Waste and Abuse


What are Fraud, Waste, and Abuse?

Fraud, as defined by the Center for Medicare and Medicaid Services, CMS, is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits.

Waste involves the intentional and unintentional, thoughtless or careless utilization, consumption, mismanagement, uses or squandering of health care benefits.

Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the health care program through improper payments that are not medically necessary.

The primary difference between fraud and abuse is a person's intent. That is, did they know they were committing a crime?

PrimeTime Health Plan’s Fraud, Waste, and Abuse Protection Mission

The mission of PrimeTime Health Plan's (PTHP) Fraud, Waste and Abuse Unit is to protect our customers, including companies, enrollees and employees against fraud, waste, and abuse by investigating all unlawful and wasteful activity directed at the corporations assets and to seek remedies for the benefit of the company's policyholders.

How PTHP Works to Protect You

PTHP maintains a committed Anti-Fraud Unit. Our unit works closely with National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC), National Health Care Anti-Fraud Association (NHCAA), the Department of Health and Human Services Office of Inspector General (HHS-OIG), the Federal Bureau of Investigation (FBI), the United States Attorney's Offices, and other partners to identify fraud, waste, and abuse. We develop cases for referral to NBI MEDIC, local and federal law enforcement authorities, support civil and/or criminal prosecutions, recover lost money, and pursue the exclusion of bad providers from the PTHP system.

What to Look For

Fraud, waste, and abuse can take many forms. Some common forms may include, but are not limited to:

  • Billing for services or supplies never provided.
  • Misrepresenting the services rendered.
  • Misrepresenting the diagnosis to justify payment for services.
  • Altering claim forms to obtain higher payment amount.
  • Soliciting, offering or receiving a kickback, bribe or rebate
  • Deliberately applying for more than one payment for the same service.
  • Unlawfully completing a Certificate of Medical Necessity.
  • Falsifying documents.
  • Misrepresenting the place of service.
  • Secret, unlawful agreements between a supplier, beneficiary, and/or other healthcare provider that results in higher costs or charges to PTHP.

For more information please visit: www.stopmedicarefraud.gov

What Happens After Suspected Fraud is Reported?

The PTHP SIU Department will begin an investigation. At that point, an investigator may request relevant medical documentation from the parties involved. All materials are then analyzed before a final determination is made.

In order for us to provide you with this service, you will need to supply the requested information. See our Privacy Statement for more information about our policies.

Please notify PTHP if you suspect healthcare fraud, waste, and abuse

CALL OUR HOTLINE: 1-866-307-3528 or
ONLINE - aultcarepthp.alertline.com

MAIL OR FAX - You can print the following PTHP Fraud Waste Abuse Form or just write the SIU Department and send to the following:
FAX - (330) 363-3125

MAIL - AultCare
SIU Department
P. O. Box 6910
Canton, Ohio 44706-0910

PTHP encourages anyone with knowledge of suspected instances of fraud, waste and abuse to report this information to the SIU. Please know this information can be reported anonymously and without fear of retaliation. Every effort is made to maintain confidentiality.
To promote an environment of open communication and reporting PTHP has and enforces a policy of non retaliation and non retribution toward any party reporting suspected fraud, waste and abuse.

Last updated: 10/01/2016