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Preventing Fraud, Waste and Abuse
As part of our efforts to improve the healthcare system, Optimum HealthCare has made a commitment to detecting and preventing fraud, waste, and abuse.
Success in this effort is essential to maintaining a healthcare system that is affordable for everyone. Optimum HealthCare is getting the word out about how physicians and other health care providers can help with fraud, waste and abuse prevention.
What is Fraud, Waste, and Abuse?
Fraud is generally defined as making a false claim in an effort to receive payment. For example, fraud in the healthcare industry can involve:
- Billing for medical services that weren't ordered or provided
- Billing for durable medical equipment items that weren't ordered or provided
- Providing services or items a person doesn't need based on his or her medical history
- "Doctor shopping" – when a patient who may or may not have a legitimate physical ailment goes from doctor to doctor to obtain multiple prescriptions for narcotic painkillers
To protect yourself from fraud, thoroughly review your Explanation of Benefits (EOB) after you receive healthcare services. If you see something that doesn't look right, you should report the situation right away.
How to Report Fraud, Waste, and Abuse
To report suspected fraud, waste, or abuse, you can contact Optimum HealthCare in one of these ways:
- Hotline: English (888) 548-0094
- Toll-Free Fax: (888) 548-0092 Local-Fax: 813-506-6176
- E-mail: ComplianceReporting@americas1stchoice.com
- Mailing Address: PO Box 152137, Tampa, FL 33684
- EthicsPoint Web Portal: www.americas1stchoice.ethicspoint.com (You will be redirected to this site.)
Another option is to download the Suspected Compliance Violation Form.
Please complete this form if you believe that fraud and/or abuse may have occurred to you, a family member, or a coworker. Any individual, entity, or group that is employed by or provides a service on behalf of Optimum HealthCare including employees, subscribers, professional providers, employees of a provider, facilities, or billing companies) may be the subject of the complaint.
The form will be forwarded to the Investigations Department for review/evaluation. You will receive a response to your complaint, unless you choose to remain anonymous.