Fraud Waste or Abuse

Preventing and Reporting Potential Fraud, Waste or Abuse

Driscoll Health Plan (DHP) is committed to finding and appropriately reporting when Medicaid and Children’s Health Insurance Program (CHIP) dollars are used in instances of fraud, waste or abuse.

Let us know if you feel that a doctor, dentist, pharmacist or other healthcare provider, or someone receiving Medicaid or CHIP benefits through DHP, is doing something wrong. They may be committing fraud, waste or abuse.

What is fraud?

Fraud is when a person is knowingly dishonest, and that action could result in unauthorized Medicaid or CHIP benefits to himself, herself or another person.

What is waste?

Waste involves spending Medicaid or CHIP dollars on resources, items or services that are not needed.

What is abuse?

Abuse involves healthcare provider practices that are not consistent with accepted medical or business practices, or questionable practices by someone receiving Medicaid or CHIP benefits that result in cost to the government that are not needed.

What types of incidents should I report?

The following are some examples of incidents of potential fraud, waste or abuse that should be reported.

By Someone Receiving Medicaid or CHIP Benefits

Using someone else’s Medicaid or CHIP card
Letting someone else use their Medicaid or CHIP card
Forging or altering a prescription
Selling prescription drugs
Obtaining controlled substances from multiple healthcare providers without the provider’s knowledge of the other prescriptions
Giving misleading or incorrect information or leaving out information to get benefits
Selling their Medicaid number to someone who bills Medicaid or CHIP for services not received
Committing identity theft to get benefits
Getting Medicaid or CHIP services that aren’t approved

By a Healthcare Provider

Falsifying documents or altering records to get items or services paid
Billing for services or goods not provided
Billing part of a service separately to be paid more when the services should be billed together to be paid correctly
Billing for complex care when the care is not complex
Billing for items or services that are not medically needed
Billing for more units than was provided
Asking someone receiving Medicaid or CHIP benefits to pay the difference between what DHP paid to the healthcare provider and what the healthcare provider billed to DHP
Knowingly asking for or receiving payment of kickbacks or bribes for referrals of Medicaid and CHIP members
Knowingly referring someone receiving Medicaid or CHIP benefits to healthcare facilities with a financial relationship to the referring healthcare provider

How do I report potential fraud, waste or abuse?

You can make a report by contacting DHP directly or by contacting the Office of Inspector General (OIG) and/or the Office of Attorney General (OAG).

Phone:
Driscoll Health Plan: 1-844-808-3170

Mail:
Driscoll Health Plan
Attn: Special Investigations Unit (SIU) Director
5001 N. McColl
McAllen, Texas 78504

Office of Inspector General
OIG FRAUD HOTLINE: 1-800-436-6184
ONLINE REPORT FORM

Office of the Attorney General
OAG PHONE: 1-512-475-4413 or 1-800-252-8011
ONLINE REPORT FORM

What information should I include in my report?

When reporting a healthcare provider, include all the information you know, such as:

The name, address and phone number for the healthcare provider
The name, address and phone number for the hospital, nursing home, home health agency or other healthcare facility
The healthcare provider’s or healthcare facility’s Medicaid number
Type of healthcare provider or healthcare facility
Witness names, addresses and phone numbers
Dates of the incident(s)
Summary of what happened

When reporting someone who receives Medicaid or CHIP benefits, include all the information you know, such as: