Fraud, Waste and Abuse
Vaya is committed to preventing and identifying fraud and abuse in the Medicaid program. You can help by reporting any suspicious billing practices or other activity you think may be fraud or abuse.
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.
The federal government estimates fraud and abuse costs U.S. taxpayers billions of dollars every year. Examples of fraud and abuse may include:
- 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.
How can I help prevent fraud and abuse?
ARE THERE SPECIFIC THINGS THAT I SHOULD DO?
- 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 for a copy of everything you sign and keep all paperwork together.
- 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 are correct.
- DO remain alert for services that were promised to you but never delivered or for unnecessary tests or procedures.
- DO be wary of providers who tell you that the item or service isn’t usually covered, but they “know how to bill” so that Vaya or Medicaid will pay.
- DO remember that nothing is ever “free.” Don’t accept offers of money or gifts for free medical care.
- DO 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.
ARE THERE SPECIFIC THINGS THAT I SHOULD
- 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 health care 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 sign any blank forms.
- 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.
How do I report fraud and abuse?
You can remain anonymous, but detailed information will help us with our investigation. (In rare cases involving legal proceedings, Vaya may have to reveal who you are.) 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 fraud, waste, and abuse using the EthicsPoint compliance portal at https://vayahealth.ethicspoint.com/.
- Call the state’s Medicaid Fraud, Waste, and Program Abuse Tip Line at 1-877-DMA-TIP1 (1-877-362-8471).
- Call the NC Medicaid Customer Service Center at 1-800-662-7030.
- Submit a Medicaid fraud and abuse confidential (private) online complaint on the NC Medicaid website.
- Call the U.S. Office of Inspector General’s Fraud Line at 1-800-HHS-TIPS (1-800-447-8477).
- Call the NC State Auditor at 1-800-730-TIPS (1-800-730-8477).