High Option Plan

Fraud, Waste and Abuse

The NALC Health Benefit Plan is committed to combating healthcare fraud, waste and abuse. Fraud, Waste and Abuse hurts everyone including members, providers, taxpayers and the NALC Health Benefit 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

Prevention Tips – Protect Yourself from Fraud

Reporting Suspected Fraud, Waste and Abuse

The NALC Health Benefit 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:

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:

http://www.gpo.gov/fdsys/pkg/USCODE-2011-title31/pdf/USCODE-2011-title31-subtitleIII-chap37-subchapIII-sec3729.pdf

 

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