CareWell Services Southwest is dedicated to protecting community resources by focusing on the detection, prevention, and reporting of fraud, waste, and abuse.
Fraud, waste, and abuse accounts for billions of dollars in losses within the Medicare and Medicaid systems annually. These losses are not just financial; they lead to higher premiums for everyone and can potentially compromise the quality of care provided to patients.
To effectively fight these issues, it is important to distinguish between the three categories:
Fraud is an intentional deception or misrepresentation made by an individual or entity with the knowledge that the deception could result in an unauthorized benefit. Examples include billing for services that were never provided or falsifying medical documentation.
Waste involves the overutilization of services or other practices that result in unnecessary costs to the healthcare system. This typically appears as redundant laboratory tests or excessive office visits that are not required for patient care.
Abuse refers to actions that are inconsistent with sound fiscal, business, or medical practices, resulting in an unnecessary cost. This includes misusing billing codes or providing services that are not medically necessary.
CareWell Services takes a proactive approach to help safeguard our community. Action begins with prevention through initial and annual trainings offered to our contracted provider agencies to ensure all partners are aware of compliance standards. To detect potential issues, CareWell Services employs several rigorous methods, including data mining, comprehensive audits, and visits to service sites.
When FWA is identified, CareWell Services takes decisive action. This may include the recovery of misspent funds, referrals to state and federal authorities such as the Office of Inspector General (OIG), and the removal of providers from the service network.
Protecting the integrity of our healthcare resources is a shared responsibility. If you suspect fraud, waste, or abuse, you are encouraged to report it immediately. Reports can be made anonymously and without fear of retaliation through the following:
MDHHS Office of Inspector General: 855-643-7283, michigan.gov/fraud
CareWell Compliance Hotline: 877-342-6495, compliancehotline@carewellservices.org