Fraud, Waste and Abuse (FWA)

IEHP has established a Fraud, Waste and Abuse Program to detect, correct, and prevent fraud, waste, and abuse on the part of IEHP Providers, Vendors, Members, Team Members, Delegated Subcontractors, and any other entity doing business with IEHP.

Fraud Prevention

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.

Examples include:

  • Knowingly billing for services or prescriptions not furnished or supplies not provided
  • Knowingly altering claim forms for a higher payment
  • Selling medicine, medical equipment, or other things received through IEHP

Waste includes overuse of services, or other practices that, directly or indirectly, result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.

Examples include:

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

Abuse includes actions that may, directly or indirectly, result in unnecessary costs, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. 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.

Examples include:

  • Billing for unnecessary medical services or medical equipment
  • Billing for brand name drugs when generics are dispensed
  • Misusing codes on a claim, such as upcoding and unbundling codes.

Report potential FWA or suspicious circumstances as they arise.  Click Here (By clicking on this link, you will be leaving the IEHP website).