Vaya Health is committed to preventing and identifying fraud, waste and abuse in the Medicaid program. The federal government estimates fraud and abuse cost U.S. taxpayers more than $15 billion every year. Medicaid fraud occurs when a healthcare provider submits a false or fraudulent claim or when a person intentionally lies or conceals income or assets to obtain government benefits.
Abuse occurs when a person or healthcare provider engages in activities that result in unreasonable or excessive cost to the Medicaid program, including a Medicaid managed care organization, such as Vaya. Examples of fraud and abuse include, but are not limited to, the following:
- You fail to report all your income or other insurance when applying for Medicaid.
- You let someone else use your Medicaid card to obtain services.
- Someone steals your Medicaid card and uses it without your permission.
- A provider bills Vaya for services or supplies that you never received.
- A provider bills Vaya for services that were not medically necessary, not coded properly or not supported by all required documentation.
- A provider’s reported credentials are false.
We encourage you to report any suspicious billing practices or other activity you think may be fraud or abuse. You can remain anonymous, but detailed information will help us with our investigation.
When you contact us, please provide the name/Medicaid ID number of the Medicaid beneficiary involved, the name of the provider, the date(s) of service, the amount of claims billed or paid and a description of the fraudulent or suspicious activity.
You can report suspected fraud and abuse in any of the following ways:
- Call the Vaya Confidential Compliance Hotline at 1-866-916-4255. This hotline is available 24/7 and allows for anonymous reporting.
- Report online using the Vaya EthicsPoint compliance portal (allows for anonymous reporting).
- Call the Medicaid fraud, waste and program abuse tip line at 1-877-DMA-TIP1 (1-877-362-8471).
- Call the U.S. Office of Inspector General’s Fraud Line at 1-800-HHS-TIPS (1-800-447-8477).
- Call the N.C. State Auditor at 1-800-730-TIPS (1-800-730-8477).
- DO protect your Medicaid number (on your Medicaid card) and your Social Security Number (on your Social Security card). Treat your Medicaid card like it is a credit card.
- DO ask questions. You have a right to know everything about your care and treatment, including costs billed to Vaya by your provider.
- DO use a calendar to record all of your service appointments and treatments. Then check your explanation of benefits carefully to make sure you got each service listed and that all the details are correct. If you spend time in a hospital, make sure the admission date, discharge date and diagnosis on your bill are correct.
- DO be wary of providers who tell you the item or service isn’t usually covered, but they “know how to bill” so that Vaya or Medicaid will pay.
- DO ask for a copy of everything you sign.
- DO remember that nothing is ever “free.” Don’t accept offers of money or gifts for free medical care.
- DO always check your pills before you leave the pharmacy to be sure you got the correct medication, including whether it’s a brand or generic and the full amount. If you don’t get your full prescription, report the problem to the pharmacist.
- DO report suspected instances of fraud.
- DON’T share your Medicaid card, Medicaid number, Social Security card or Social Security Number with anyone except your doctor or other authorized provider.
- DON’T let friends, relatives or anyone else “borrow” your Medicaid card.
- DON’T ask your doctor or other healthcare provider for treatment or care that you do not need or let anyone else persuade you to see a doctor for care or services you don’t need.
- DON’T accept gifts or kickbacks from your provider.
- DON’T share medical records or other sensitive information with anyone except Vaya or another insurance company, or a doctor, agency, clinic, hospital or other healthcare provider.
- DON’T accept medical supplies from a door-to-door sales representative. If someone comes to your door claiming to be from Medicare or Medicaid, remember that Medicare and Medicaid don’t send representatives to your home to sell products or services.
- DON’T be influenced by certain media advertising about your health. Many internet, television and radio ads don’t have your best interest at heart.
