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Medicare Fraud and Compliance Concern

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Report Fraud, Waste & Abuse and Compliance Concerns

According to the Department of Health and Human Services, "fraud is the intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the deception could result in some unauthorized benefit to himself/herself or some other person." Some examples of Medicare fraud are:

  • Billing Medicare for services or items you never received.
  • Billing Medicare for services or equipment that is different from what you received.
  • Use of another person's Medicare card to get medical care, supplies or equipment.
  • Billing Medicare for home medical equipment after it has been returned.

Scott and White Health Plan’s Special Investigative Unit (SIU) and auditors utilize fraud detection software for medical and prescription claims, investigate any suspicious claims and follow necessary actions.

Fraud Protection and Prevention

Because Medicare fraud costs the Medicare program millions of dollars annually, people with Medicare pay for it with higher premiums. You can help prevent, avoid and detect fraud by following some simple steps:

  • Review your monthly Scott and White Health Plan Explanation of Benefits (EOB) and ensure that you received all services stated on the document. The EOB is a listing of medications that you received, the co-payment that you paid and the amount that was billed to your insurance for the previous month.
  • Review your Medicare Summary Notice (MSN) and ensure that you received all services stated on the document. The MSN shows what Medicare was billed for, what Medicare paid and what you owe.
  • Don't ever give out your Medicare Health Insurance Claim Number (on your Medicare card) except to your physician or other Medicare provider.
  • Be cautious when you are offered free testing or screening in exchange for your Medicare card number.

If you find a suspicious charge on your EOB or MSN, call your provider first. It could be a simple error that can be easily corrected. If you still suspect fraud after speaking with them, you can contact the Scott and White Health Plan Hotline, The Scott and White Health Plan Compliance Officer, or contact the Office of the Inspector General Hotline. The hotlines offer a confidential means of reporting information.

Contact Scott and White Health Plan If You Suspect or Want to Report Fraud:

Scott and White Health Plan Compliance Officer: 1-214-820-8888

Scott and White Health Plan Helpline: 1-888-484-6977

Anonymous: 1-888-484-6977

Scott and White Health Plan Compliance Helpline

Scott and White Health Plan

Compliance Department

1206 West Campus Drive

Temple, TX 76502

Fax: 1-254-298-3508

Contact the Office of the Inspector General:

Phone: 1-800-436-6184

TTY: 1-800-337-4950

Website: http://oig.hhsc.state.tx.us

US Department of Health and Human Services

Office of Inspector General

ATTN: OIG Hotline Operations

PO Box 23489

Washington, DC 20026

If you have specific information proving Medicare fraud, please provide as much identifying information as possible regarding your concern. Such information should include the subject's name, address and phone number. Details regarding the allegation should include the basics of who, what, when, where, why and how.

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