Consumer Driven Health Plan
Fraud, Waste and Abuse
The NALC Consumer Driven Health Plan is committed to combating healthcare fraud, waste and abuse. Fraud, Waste and Abuse hurts everyone including members, providers, taxpayers and the NALC Consumer Driven Health Plan. Fraud, Waste and Abuse increases the cost of health care for everyone and increases Federal Employees Health Benefits (FEHB) Program premiums.
What is Fraud, Waste and Abuse?
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.
Waste is the expenditure, consumption, mismanagement, use of resources, practice of inefficient or ineffective procedures, systems, and/or controls to the detriment or potential detriment of entities. Waste is 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 the FEHB Program, 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. Abuse cannot be differentiated categorically from fraud because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.
Examples of Fraud, Waste and Abuse
- Billing for services that were never rendered
- Misrepresenting who provided the services, altering claim forms, electronic claim records or medical documentation
- Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary
- Waiving patient co-pays or deductibles and over-billing the FEHB plan
- Misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered)
Prevention Tips – Protect Yourself from Fraud
- Carefully review explanation of benefits (EOBs) statements that your receive from us
- Do not give your plan identification number over the telephone or to people you do not know, except for your health care provider, authorized health benefits plan, or OPM representative
- Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid
- Periodically review your claims history for accuracy to ensure we have not been billed for services you did not receive
Reporting Suspected Fraud, Waste and Abuse
The NALC Consumer Driven Health Plan has a comprehensive Fraud, Waste and Abuse program. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call the SIU Hotline at 888-636-NALC (6252) and explain the situation. The SIU will investigate the situation and try to resolve the issue.
If we do not resolve the issue, call:
THE HEALTH CARE FRAUD HOTLINE: 877-499-7295
OR GO TO: www.opm.gov/oig
OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415-1100
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
For more information on healthcare fraud, waste and abuse, refer to the official Plan brochure.
To learn more about the False Claims Act (31 USC 3729) visit: