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Provider Manual

Compliance - Fraud, Waste and Abuse

Last Updated on August 28, 2018

Fraud, waste and abuse

Security Health Plan of Wisconsin is committed to detecting, correcting, and preventing health care fraud, waste and abuse. Fraud, waste and abuse within the health care system results in higher insurance costs to all persons and entities including the Medicare/Medicaid program, individual health plan members, group plans and business partners, as well as state and federal governments that are funded by taxpayers. Security Health Plan takes all allegations of fraud, waste and abuse or other compliance issues very seriously.

Fraud is an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself/herself or some other person. Fraud is an act that is committed knowingly, willfully, recklessly, or intentionally. These acts result in either benefit to oneself or some other party. Fraud is a serious matter and carries criminal penalties. Fraud is both a state and federal offense.

Waste is the intentional or unintentional, thoughtless or careless expenditures, consumption, mismanagement, use, or squandering of resources to the detriment or potential detriment of entities, but without an intent to deceive or misrepresent. Waste also includes incurring unnecessary costs as a result of inefficient or ineffective practices, systems or controls.

Abuse describes incidents or practices that either directly or indirectly results in unnecessary costs that are wasteful to the Medicare/Medicaid program or other Security Health Plan programs, although it is not an intentional misrepresentation. Abuse can also occur with excessive charges, improper billing practices, payment for services that do not meet recognized standards of care and payment for medically unnecessary services. Abuse can occur in financial or non-financial settings. Abuse can be a questionable practice, which is inconsistent with accepted medical, governmental or business policies.

Reporting health care fraud, waste and abuse

Health care providers are encouraged to consider reporting alleged misconduct to government authorities such as the Office of Inspector General or the Department of Justice. All health care providers doing business with Medicare are eligible to disclose fraudulent conduct under the Provider Self-Disclosure Protocol.

To report fraud, waste and/or abuse in Medicare/Medicaid programs administered by the Department of Health and Human Services, contact:

  • Security Health Plan by calling our confidential compliance hotline for medical concerns at 1-855-274-5540 (external compliance hotline) or our confidential Pharmacy Part D hotline for prescription drug concerns at 1-888-472-2363.
  • Office of the Inspector General (OIG) Hotline between 7 a.m. and 4:30 p.m., Monday through Friday at 1-800-447-8477 (TTY: 1-800-377-4950). Or fill out this form. Medicare will not use names if anonymity is requested.
  • Center for Medicare and Medicaid Services (CMS) between 7 a.m. and 7 p.m., Monday through Friday at 1-800-633-4227 (TTY: 1-800-325-0778).
To learn more from CMS about fraud, waste and abuse click hereIf you have questions about fraud, waste and abuse or another compliance concern, contact Security Health Plan Customer Service between 8 a.m. and 5 p.m. Monday through Friday at 1-877-998-0998 (TTY: 711).