Addressing Fraud, Waste and Abuse
As part of our efforts to improve the health care system and our organization, Argus Dental & Vision, Inc. (Argus) has made a commitment to detecting and preventing fraud, waste, and abuse. Success in this effort is essential to maintaining a health care system that is affordable for everyone. Below is information on how physicians, other participating providers, and business partners can help Argus with detecting, preventing, and correcting fraud, waste, and abuse.
What are Fraud, Waste, and Abuse?
Fraud is defined as 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 includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs to the health care system, including the Medicare and Medicaid Programs. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare or Medicaid Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
One of the primary differences between fraud, waste, and abuse is intent and knowledge. Fraud requires intent to obtain payment and the knowledge that the actions are wrong. Waste and abuse may involve obtaining an improper payment or creating an unnecessary cost to the Medicare or Medicaid Program, but does not require the same intent and knowledge.
How to Report Fraud, Waste, and Abuse
If you suspect fraud, waste, or abuse in the health care system, you must report it to Argus, or one of the external sites listed below, so that it can be investigated. Your actions may help to improve the health care system and reduce costs for our members, customers, and business partners.
To report suspected fraud, waste, or abuse, please contact the Argus Compliance Officer through one of the methods listed below:
• Compliance Hotline: (813) 283-1276
• Compliance Fax: (813) 347-9270
• Compliance E-mail: [email protected]
• Physical Mail: Argus Dental & Vision, Inc., Attn: Compliance Officer, 4010 W State Street, Tampa, FL 33609
There are also many external sites provided by federal and state regulators where fraud, waste, and abuse can be reported.
• State Attorney General: 1-866-966-7226
• Agency for Health Care Administration (AHCA), Medicaid Program Integrity: 1-888-419-3456
• Dept. of Financial Services, Div. of Insurance Fraud: 1-800-378-0445
• Office of Inspector General (OIG): http://oig.hhs.gov
• Department of Health and Human Services (DHHS): www.hhs.gov/ocr/hipaa
• Centers for Medicare and Medicaid Services (CMS): www.cms.gov