Fraud, Waste, and Abuse

Addressing Fraud, Waste, and Abuse

As part of our efforts to improve the healthcare system in Maine and offer affordable health insurance plans to our Members, Community Health Options® has made a commitment to detecting, investigating, correcting, and preventing fraud, waste, and abuse.

What are 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 any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)

Examples of Health Care Provider Fraud are (but not limited to):

  • Billing for services not actually performed.
  • Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
  • Misrepresenting procedures performed to obtain payment for non-covered services.
  • Upcoding: billing for a more costly service than the one actually performed.
  • Unbundling: billing each stage of a procedure as if it were a separate treatment.
  • Waiving member copays or deductibles and over-billing the insurance carrier or benefit plan.

Examples of Health Care Member Fraud are (but not limited to):

  • Submitting reimbursement requests for services or medications not received.
  • Forging or altering bills or receipts.
  • Using someone else's coverage or insurance card.
  • Intentionally submitting incorrect information on an enrollment application.

Waste is the overutilization of services resulting in unnecessary costs to the health care system.

Abuse is payment for items or services when there is no legal entitlement to that payment and the health care provider billing Community Health Options has not knowingly and/or intentionally misrepresented facts in order to obtain payment. Abuse includes any action that may result in unnecessary costs to the health care system, improper payment for services, or services that are not medically necessary.

How do I report suspected fraud, waste or abuse?

Please notify Community Health Options if you suspect healthcare fraud, waste, or abuse has taken place by using the following resources:

  • Phone: 207-330-2397. All calls are confidential and can be made Monday through Friday, 8:00 a.m. to 5:00 p.m. Calls made after hours will be sent to a secure voicemail.
  • Email: ReportFWA@HealthOptions.org. E-mail is secure for your protection.
  • Write to us:
    Community Health Options
    Mail Stop 100
    Attn: Department of Fraud Waste & Abuse
    PO Box 1121
    Lewiston, ME 04243

All information received is strictly confidential. As specified under the HIPAA regulation, section 164.512 (f), Community Health Options may make referrals to law enforcement agencies for further investigation.

What happens after a report is submitted?

Community Health Options' Fraud Waste and Abuse team will begin researching materials such as claims records. After the claims records have been reviewed, a member of Community Health Options’ team may request relevant medical documentation from the parties involved. All materials are then analyzed before a final determination is made.