Fraud, Waste and Abuse
Let us fight together to combat Fraud, Waste and Abuse
Health care fraud, waste and abuse account for billions of dollars in losses each year in the United States.
Care1st Health Plan Arizona and ONECare by Care1st Health Plan Arizona, Inc. (HMO SNP) (“Care1st”) is committed to fighting fraud waste and abuse to safeguard the health and welfare of our members. Most people and organizations that work with Care1st are honest and mean well. However, anyone can commit fraud and abuse. There are penalties under the law for committing fraud and abuse, such as criminal and/or civil charges.
It is very important that you report any cases of suspected doctor and/or member fraud and abuse to our Compliance Department. You don’t have to tell us who you are. Be sure to leave enough information so we can appropriately investigate. Care1st will not retaliate against you for reporting suspected fraud, waste and abuse. See our contact information below for ways to report suspected fraud, waste and abuse.
- An example of doctor fraud is a doctor billing for services that were not given to you or billing for the same service twice.
- Doctor abuse happens when doctor actions (planned or unplanned) cause needless costs to a health care program, such as AHCCCS and Medicare.
- An example of doctor abuse is billing for services that are not medically necessary.
Members commit fraud by cheating or lying (on purpose) to a health care program, such as AHCCCS or Medicare, in order to obtain a service or benefit at the government’s expense.
An example of member fraud is a member sharing their Care1st or ONECare ID card with others, or sharing another person’s ID card in order to get services.
Members commit abuse when their actions cause loss of money to a health care program.
An example of member abuse is when a member does not report having other insurance or not updating information with other insurance.
- If you have other insurance, please inform AHCCCS. Remember to keep your information current with your other insurance. At times, your other insurance may also need additional information from you in order to pay a doctor or hospital for treating you (for example: accident information and/or forms your other insurance may require you to submit every year). If you do not keep your information current or give additional information when asked, your other insurance may deny payment to a doctor or hospital until you give the requested information they need. When a doctor or hospital requests payment from Care1st, we cannot consider payment without knowing if your other insurance will pay a doctor or hospital. You have a responsibility to keep your other insurance information current and to give additional information to your other insurance as needed and as soon as possible.
In 2011 AHCCCS began putting photos of members on the web tool that doctors use to see if a member is eligible. The photos are one of many efforts by AHCCCS to help protect members and stop fraud. AHCCCS gets the photos from the Motor Vehicle Division (MVD) if you have an Arizona driver’s license or State ID card. When providers pull up the AHCCCS eligibility verification screen, they will see your picture (if available) with your coverage details.
Ways to report suspected provider and/or member fraud, waste and abuse
If you suspect provider and/or member fraud or abuse,
Call our Compliance Department “hotline” at 1-866-364-1350. The hotline is anonymous and available 24/7.
You may report FWA directly to AHCCCS at www.azahcccs.gov/fraud/reportfraud
Write to us:
Care1st Health Plan Arizona, Inc.
2355 E. Camelback Rd., Suite 300
Phoenix, AZ 85016
Medical Identity Theft & More Info About Medicaid/Medicare Fraud
Medical identity theft occurs when someone steals your personal information (like your name, Social Security number, Care1st/ONECare ID number) to obtain medical care, buy drugs, or submit fake billings to Medicare in your name.
Medical identity theft can disrupt your life, damage your credit rating, and waste taxpayer dollars. The damage can be life-threatening to you if the wrong information ends up in your personal medical records.
Potect Your Personal Information
- Guard your Social Security number and your Care1st/ONECare ID. Treat them like you would treat your credit cards.
- If it's free, they don't need your number! Be suspicious of anyone who offers you free medical equipment or services and then requests your Medicare number.
- It's illegal, and it's not worth it! Do not let anyone borrow or pay to use your Care1st/ONECare ID card, or your identity.
Report and DETECT
Watch Out for These Common Fraud Schemes
- Just walk away if people approach you in parking lots, shopping centers, or other public areas and offer free services, groceries, transportation, or other items in exchange for your Care1st or ONECare ID number.
- Simply hang up the phone if someone calls you claiming to be conducting a health survey and asks for your Care1st or ONECare ID number.
- Don't give your information to telephone marketers who claim to be from Medicare or Social Security and asks for payment over the phone or Internet. They may want to steal your money.
Check Your Medical Bills and Credit Reports
- Were you charged for any medical services or equipment that you didn't get?
- Were you charged for covered services?
- Do the dates of services and charges look unfamiliar?
- Were you billed for the same thing twice?
- Does your credit report show any unpaid bills for medical services or equipment you didn't receive?
- Have you received any collection notices for medical services or equipment you didn't receive?
U.S. Department of Health & Human Services & US Department of Justice:
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