Fraud, Waste, + Abuse

Fraud, Waste, + Abuse

See something? Say something.

We are committed to complying with all applicable laws, including, without limitation, Oregon’s False Claims Act and the federal False Claims Act Examples of Fraud, Waste, and Abuse.

We are all hurt by fraud, waste, and abuse in the health care system. Every dollar that is spent on fraudulent, abusive, or wasteful activities is money that can’t be spent where it is needed most.

We encourage you to report incidents of suspected fraud, waste, or abuse. Everyone has the right to report fraud, waste, and abuse anonymously and are protected under the applicable Whistleblower laws.

Health Share reports all verified cases of fraud to the Medicaid Fraud Control Unit (MCFU).

Here’s how you can report:

  • Call the anonymous Health Share Compliance Hotline at 503-416-1459. 
  • Call the State of Oregon Department of Human Services (DHS) Fraud Hotline: 888-372-8301. 
  • Complete and return the Fraud, Waste, and Abuse reporting form.
    • You can fax the form to us at 503-459-5749 or mail it to us at:
      Compliance Officer
      Health Share of Oregon
      2121 SW Broadway, Suite 200
      Portland, OR 97201

What is Fraud?

Fraud is an intentional deception or misrepresentation, whether by act or omission, made by a person with the knowledge that the deception could result in some unauthorized benefit to himself/herself or some other person.

What is Waste?

Waste is health care spending that can be eliminated without reducing quality of care. It includes inefficient use or management of resources, unnecessary expenses, or procedures that cannot reasonably be expected to yield better outcomes.

What is Abuse?

Abuse is when someone accidentally gives false information to the Government or a Government contractor to get money or a benefit. For example, accidentally billing a follow-up visit as a higher paying new patient visit.

Examples of Fraud

  • Billing for services not provided (phantom billing)
  • Accepting money for referrals (kickbacks)
  • Billing for unnecessary services or tests
  • Billing twice for the same services
  • Dispensing generic drugs and billing for brandname drugs
  • Billing for lengthy services that only take a short period of time

Examples of Fraud, Waste, and Abuse:

Examples of Fraud, Waste, and Abuse include, without limitation, any one, combination of, or all of the following:

  1. Providers, other CCOs, or Subcontractors that intentionally or recklessly report encounters or services that did not occur, or where products were not provided.
  2. Providers, other CCOs, or Subcontractors that intentionally or recklessly report overstated or upcoded levels of service.
  3. Providers, other CCOs, or Subcontractors intentionally or recklessly billed Contractor or OHA more than the Usual Charge to non-Medicaid Recipients or other insurance programs.
  4. Providers, other CCOs, or Subcontractors altered, falsified, or destroyed Clinical Records for any purpose, including, without limitation, for the purpose of artificially inflating or obscuring such Provider’s own compliance rating or collecting Medicaid payments otherwise not due. This includes any intentional misrepresentation or omission of fact(s) that are material to the determination of benefits payable or services which are covered or should be rendered, including dates of service, charges or reimbursements from other sources, or the identity of the patient or Provider.
  5. Providers, other CCOs, or Subcontractors that intentionally or recklessly make false statements about the credentials of persons rendering care to Members.
  6. Providers, other CCOs, or Subcontractors that intentionally or recklessly misrepresent medical information to justify Referrals to other networks or out-of-network Providers when such parties are obligated to provide the care themselves.
  7. Providers, other CCOs, Subcontractors that intentionally fail to render Medically Appropriate Covered Services that they are obligated to provide to Members under this Contract, any Subcontract with the Contractor, or Applicable Law.
  8. Providers, other CCOs, or Subcontractors that knowingly charge Members for services that are Covered Services or intentionally or recklessly balance-bill a Member the difference between the total Fee-for-Service charge and Contractor’s payment to the Provider, in violation of Applicable Law.
  9. Providers, other CCOs, or Subcontractors intentionally or recklessly submitted a claim for payment when such party knew the claim:
    (i)had already been paid by OHA or Contractor,
    (ii) had already been paid by another source.
  10. Any case of theft, embezzlement or misappropriation of Title XIX or Title XXI program money.
  11. Any practice that is inconsistent with sound fiscal, business, or medical practices, and which:
    (i) results in unnecessary costs,
    (ii) results in reimbursement for services that are not medically necessary, or
    (iii) fails to meet professionally recognized standards for health care.
  12. Evidence of corruption in the Enrollment and Disenrollment process, including efforts of Contractor employees, State employees, other CCOs, or Subcontractors to skew the risk of unhealthy Member or potential Members toward or away from Contractor or any other CCO.
  13. Attempts by any individual, including Contractor’s employees, Providers, Subcontractors, other CCOs, Contractor, or State employees or elected officials, to solicit kickbacks or bribes. For illustrative purposes, the offer of a bribe or kickback in connection with placing a Member into a carved out program, or for performing any service that such persons are required to provide under the terms of such persons’ employment, this Contract, or Applicable Law.