Fraud, Waste, & Abuse
If you have a concern or if you suspect that a Community First Health Plans health care provider, pharmacist, or Member is doing something wrong – please let us know. Doing something wrong could be classified as fraud, waste, or abuse.
OUR PLAN TO PREVENT FRAUD, WASTE, AND ABUSE
What is Fraud, Waste, and Abuse (FWA)?
Fraud
Fraud is when you do something wrong on purpose to gain a benefit. It is intentional.
Waste
Waste is being careless or misusing a service or item in a way that it was not intended to be used.
Abuse
Abuse is behaving in a manner that goes against known acceptable practices and results in unnecessary costs.
Examples of FWA
Health Care Provider
- Billing for services, procedures, or supplies that were not provided or needed
- Billing a claim for a more expensive procedure or service than what was actually performed
- Billing for a covered service when the service provided was not covered
- Omitting or misrepresenting information about a condition, symptom, or service performed
- Unbundling charges (taking an overall procedure and billing each part or step separately to receive higher reimbursement)
- Accepting money for patient referrals
- Waiving patient copays or deductibles for services that were prepaid or paid in full by the health insurer
Member/Patient
- Sharing your Member ID card with someone else
- Adding someone to your insurance policy who is not eligible for coverage
- Receiving narcotic prescriptions from several different doctors or pharmacies, dishonestly
- Forging or altering bills or receipts
- Filing claims for services or medications not received
- Lying about your physical address to obtain coverage
How to Report FWA
To report FWA, choose one of the following:
1. Report directly to Community First by completing the online form at the bottom of this page.
2. Report directly to Community First by phone, email, fax, or regular mail using the Suspicious Activity Report form and provide as much information as possible.
Phone/Fax
Community First Anti-Fraud Hotline
210-358-6332 (Toll-free 1-877-225-7152)
210-358-6405 (Fax)
Email
Community First Special Investigation Unit
SIURequest@cfhp.com
Mail
Community First Health Plans
Attn: Special Investigation Unit
12238 Silicon Drive, Suite 100
San Antonio, Texas 78249
3. Call the Office of Inspector General (OIG) Hotline at 1-800-436-6184 or complete the OIG form online
More Information
When reporting a provider (a doctor, dentist, counselor, etc.), include the following:
- Name, address, and phone number
- Name and address of the facility (hospital, nursing home, home health agency, etc.)
- Medicaid number of the provider and facility (if you have it)
- Type of provider (doctor, dentist, therapist, pharmacist, etc.)
- Names of other witnesses who can help in the investigation
- Dates of events
- Summary of what happened
When reporting a patient or a Member, include the following:
- Name
- Date of birth, Medicaid ID number, and Social Security Number (if you have it)
- Address and other contact information (if you have it)
- Specific details about the fraud, waste, or abuse
- Names of other witnesses who can help in the investigation
- Dates of events
- Summary of what happened