Report Fraud, Waste and Abuse

What is Fraud, Waste and Abuse (FWA)?

Fraud is an intentional misrepresentation that may result in unauthorized costs to a healthcare program.

Abuse is a practice that is inconsistent with sound medical or business practices that may directly or indirectly result in unnecessary costs to a healthcare program.

Waste is the inappropriate use of healthcare funds or resources without a justifiable need to do so.

There are differences between Fraud, Waste, and Abuse. These differences are based upon intent and knowledge. Fraud requires the person to have an intent to obtain payment and the knowledge that their actions are wrong. Waste and Abuse may involve obtaining an improper payment but does not require the same intent and knowledge.

Eliminating FWA in the delivery of healthcare is an obligation, responsibility, and legal requirement of all Vitality Health Plan employees and the health plan contracted providers.

Fraud and Member Protection Resources

Help Fight Medicare Fraud
https://www.medicare.gov/forms-help-resources/help-fight-medicare-fraud

Officer of Inspector General (OIG)
https://oig.hhs.gov/compliance/physician-education/index.asp

Accessing the CMS training material (English version)

  1. Navigate to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html, opens new tab.
  2. Scroll to the “Fraud and Abuse-related Resources” section.
  3. Click on “FAQs Medicare Parts C and D Compliance and Fraud, Waste, and Abuse Training.”
  4. Follow the instructions within the CMS document.

How to Report Fraud, Waste and Abuse (FWA)

To report suspected fraud, waste and abuse (FWA), you may contact Vitality Health Plan in one of these ways:

You have the option for your report to remain anonymous. All information received or discovered by the Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, Vitality Health Plan legal department, or Vitality Health Plan Senior Management).

Messages received on holidays and outside of our business hours will be returned within 1 business day for filing a report with our Special Investigations Unit (SIU).
Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to February 14. From February 15 to September 30 hours are 8 a.m. to 8 p.m. Monday through Friday. Messages received on holidays and outside of our business hours will be returned within one business day.