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
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:
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 write the SIU Department and send to the following:
MAIL - AultCare / PrimeTime Health Plan
P. O. Box 6910
Canton, Ohio 44706-0910
FAX - (330) 363-3066
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.