Fraud, Waste, and Abuse or Compliance Concerns
Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme to obtain financial or personal gain.
Waste is over utilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system. It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.
Abuse includes any action(s) that may, directly or indirectly, result in one or more of the following:
- Unnecessary costs to the health care system
- Improper payment for services
- Payment for services that fail to meet professionally recognized standards of care
- Services that are medically unnecessary
Fraud Protection and Prevention
Scott and White Health Plan’s Special Investigative Unit (SIU) and auditors utilize fraud detection software for medical and prescription claims, investigate any suspicious claims, and follow necessary actions.
Because healthcare fraud costs millions of dollars annually, Scott and White Health Plan proactively seeks opportunity to minimize fraudulent activity through education, timely identification of issues, and ongoing monitoring efforts. You can help prevent, avoid, and detect fraud by following some simple steps:
- Review your monthly Scott and White Health Plan Explanation of Benefits (EOB) and ensure that you received all services stated on the document
- Don't ever give out your health insurance identification card except to your physician or other providers.
If you find a suspicious charge on your EOB or MSN, call your provider first. It could be a simple error that can be easily corrected. If you still suspect fraud after speaking with them, you can contact the Scott and White Health Plan Ethics line or contact the Compliance Officer directly. The hotline offer a confidential means of reporting information.
Scott and White Health Plan Compliance Officer: 214-820-8888
Scott and White Health Plan Helpline: 1-888-484-6977
Scott and White Health Plan Compliance Helpline
Scott and White Health Plan - Compliance Department 1206 West Campus Drive Temple, TX 76502 Fax: 1-254-298-3508
You may also contact the Texas Department of Insurance at 1-800-252-3439. You can download the Fraud Reporting Form located on the TDI website.
1. Email to FraudReport@tdi.texas.gov
2. Fax to 512-490-1001
3. Mail to:
Texas Department of Insurance
PO Box 149336
Austin, TX 78714-9336