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Fraud and Abuse

Most providers and members are honest. Some are not. Fraud is when a provider or member knowingly gives false information that allows someone to get a benefit that is not allowed. Waste is when a member gets a benefit that is not medically necessary. Abuse is when providers or members knowingly take actions that result in unnecessary cost or services.

Billions of dollars are lost to healthcare fraud every year. That means money is paid for services that may never have been given. It could also mean that the service that was billed was not the one that was performed.

Here are some other examples of provider and member fraud, waste and abuse:

  • Billing for a more expensive service than what was actually given
  • Billing more than once for the same service
  • Billing for services you did not get
  • Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary
  • Filing claims for services or medications not received
  • Forging or altering bills or receipts
  • Misrepresenting procedures performed to get payment for services that are not covered
  • Waiving patient co-pays or deductibles
  • Using someone else’s WellCare of Kentucky ID card
  • Sharing your own WellCare of Kentucky ID card with another person

To Report Fraud, Waste and Abuse with WellCare of Kentucky

One way you can help stop fraud, waste and abuse is to review your Explanation of Benefits (EOB) when you get it in the mail. Look for any service that you did not receive or any provider you did not see.

If you think fraud that has occurred, call our 24-hour fraud hotline. The toll-free number is 1-866-685-8664. It’s private. You can leave a message without leaving your name. If you do leave a number, we’ll call you back. We’ll call to make sure the information we have is complete and accurate.

You can also report fraud using this online form. Giving a report through the web is kept private too.

To Report Fraud, Waste and Abuse with the State of Kentucky

Call the Kentucky Medicaid Division of Program Integrity toll-free at: 1-800-372-2970.