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Fraud, Waste & Abuse

Category: Partnering to Deliver Better Care

Introduction to Fraud, Waste & Abuse

Eliminating fraud, waste, and abuse (FWA) in the delivery of health care is an obligation, responsibility, and legal requirement of all SCAN Health Plan employees, including our contracted providers. This page provides important requirements and expectations in delivering excellence to patients while minimizing risks to yourself and SCAN. 

 

Definitions:

Fraud - intentional misrepresentation that may result in unauthorized costs to the program.

Abuse - practices that are inconsistent with sound medical or business practices that may directly or indirectly, result in unnecessary costs to the program.

Waste – the use of health care funds without a real need.

 

Differences:

There are differences between fraud, waste, and abuse. One of the primary differences is intent and knowledge. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge.

 

For More Information:

Office of Inspector General Physician Training Tools

SCAN P&P False Claims Act and Deficit Reduction Act

Fraud and Member Protection Resources

 

Fraud Waste and Abuse (FWA) Training

First tier, downstream and related entities (FDRs) may develop and provide their own FWA training so long as it meets CMS requirements. If an FDR does not provide FWA training that meets CMS requirements and related CMS guidance and has not been “deemed” compliant, SCAN requires that FDRs’ employees take the CMS developed training which is accessible at the CMS Medicare Learning Network (MLN) at http://www.cms.gov/MLNProducts. For details on accessing the FWA training and education on the MLN website, select the link below or see the May 8, 2012, HPMS memo regarding Fraud, Waste and Abuse Training and Education Guidance

 

Accessing CMS’ General Compliance Training

 

Reporting Potential Compliance Issues and/or Fraud, Waste and Abuse

You have several ways to report – to SCAN, to Ethicspoint, an independent organization, or to the Office of Inspector General (OIG).  

To report to SCAN:

Call Member Services at 1-800-559-3500 (TTY User: 711) 8:00 a.m. – 8:00 p.m. PST – Monday – Friday, 9:00 a.m. – 4:00 p.m. – Saturday. Messages received on holidays and outside of our business hours will be returned within 1 business day.

Online:  Fraud, Waste and Abuse Form

Email:  FraudWaste&AbuseProg@scanhealthplan.com

 

To report to Ethicspoint:

Call: 1-877-863-3362

Online:  www.ethicspoint.com

 

To report to OIG:

Call: 1-800-HHS-TIPS (1-800-447-8477)

Online:  https://forms.oig.hhs.gov/hotlineoperations

 

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