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Provider Manual

Compliance - Fraud, Waste and Abuse

Last Updated on May 12, 2021

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:

  • Knowingly and willfully executing, or attempting to execute, a scheme to defraud any health care benefit program.
  • Obtaining any money or property owned or controlled by any health care benefit program, by means of false or fraudulent pretenses/representation.

Waste is:

  • Overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to any health care benefit program.
  • Generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Abuse includes:

  • Actions that may, directly or indirectly, result in unnecessary costs to any health care benefit program.
  • Involves payment for items or services when there is no legal entitlement to that payment and the recipient has not knowingly and/or intentionally misrepresented facts to obtain payment.

Reporting health care fraud, waste and abuse

Health care providers are expected to report alleged misconduct to government authorities such as the Office of Inspector General or the Department of Justice. 

To report fraud, waste and/or abuse, contact:

  • Security Health Plan by calling our confidential compliance hotline  at 715-221-9570, the External Compliance Hotline number is 1-855-274-5540, and the Security Health Plan Pharmacy Medicare Part D Hotline number is 1-888-472-2363 or 715-221-9909.
  • 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.
  • 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).