Special Investigations

What is Fraud, Waste and Abuse (FWA)?

Fraud is an intentional act of deception, misrepresentation, or concealment to gain something of value. Fraud often involves criminal behavior.

Waste occurs when poor or inefficient practices result in unnecessary healthcare expenditures to a government program.

Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse often involves actions that are inconsistent with accepted medical and/or business practices.

Detect, Correct and Prevent FWA

How do you detect fraud, waste and abuse?

  • Verify information provided to you
  • Ensure data/billing is both accurate and timely
  • Be on the look out for suspicious activity
  • Report any suspected fraud, waste or abuse to the SIU/Compliance Department. Do not be concerned about whether it is fraud, waste or abuse. Just report any concerns you have to the SIU/Compliance Department.

How do we correct FWA?

  • Educate/Recoveries/Corrective Actions

How do we prevent FWA?

  • Continued monitoring/Corrective Actions

Reporting to federal and state agencies (NBI MEDIC, DOI, TDI, U.S. Attorney General)

Delivering healthcare – one community, one family, one life at a time.