Fraud, Waste and Abuse

How to Report Fraud, Waste and Abuse

The Compass Rose Health Plan is committed to keeping our members safe from health care fraud, waste and abuse. As a health care consumer, be sure to know how to recognize what is considered fraud, waste or abuse, and when to report it.

What is fraud, waste and abuse?  

Fraud

Fraud is knowingly and willfully executing or attempting to execute, a scheme or artifice to defraud any healthcare 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 healthcare benefit program.

Some examples of fraud are:

• Billing for services not rendered
• Misrepresenting who provided the services
• Falsifying a patient’s diagnosis to justify tests or other procedures that aren’t medically necessary 

Waste 

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.

Examples of waste include:  

• Prescription medication refill errors
• Performing unnecessary diagnostic procedures

Abuse

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 includes any action that may result in:

• Unnecessary costs to the FEHB program
• Improper payment
• Payment for services that fail to meet professionally recognized standards of care
• Services that are not medically necessary

Some examples of abuse are:

• Waiving patient co-pays or deductibles and over-billing the FEHB plan
• Misusing procedure or diagnosis codes
• Billing for services that should not be paid for by the FEHB Program such as never events (preventable health care acquired conditions)

How to report fraud, waste or abuse

If you suspect fraud, waste or abuse, report it to us and we will investigate. Here are the Fraud, Waste and Abuse Hotlines:  

• Compass Rose Health Plan Fraud, Waste and Abuse Line: (866) 368-7227 (option 7)  
• UMR Fraud and Abuse Hotline: (800) 356-5803  
• Optum Rx: (800) 557-5785
• Medicare: Call toll-free 1-800-MEDICARE (1-800-633-4227). TTY, call toll-free 1-877-486-2048, 24 hours a day, 7 days a week.