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.

Learn more about how to identify Enrollment Fraud by watching this video:
Look out for Enrollment Fraud

Waste is generally defined as overusing services or a misuse of resources that result in unnecessary costs to the Medicare Program.

  • Conducting excessive office visits or writing excessive prescriptions
  • Prescribing more medications than necessary for the treatment of a specific condition
  • Ordering excessive laboratory tests

Abuse is generally defined as payment for items or services when payment is not legally allowed and the provider has not knowingly misled the Plan or Medicare.

  • Billing for unnecessary medical services
  • Billing for brand name drugs when generics are dispensed
  • Charging excessively for services or supplies
  • Misusing codes on a claim, such as up-coding or unbundling codes

How to Report Fraud, Waste, and Abuse

To report suspected fraud, waste, abuse, non-compliance or HIPAA violations anonymously, you can contact Optimum HealthCare in one of these ways:

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.

You will receive a response to your complaint, unless you choose to remain anonymous.

Last updated 10/01/2023