Fraud, Waste and Abuse

• Phone: 877-957-1300
• Fraud Hotline: 888-411-4959
• Email: FraudandAbuse@wellsense.org
• Fax: 866-750-0947
• Mail:
  WellSense Health Plan
  Attn: Special Investigations Unit
  1155 Elm Street, 5th Floor
  Manchester, NH 03101

• Phone: 603-271-9258
• Toll Free (NH Residents): 800-852-3345, ext. 9258
• Fax: 603-271-4472 or
• Mail:
  Department of Health and Human Services
  Office of Improvement and Integrity, Special Investigations
  129 Pleasant St., Brown Building
  Concord, NH 03301

If you suspect PROVIDER Fraud, Waste or Abuse, you should report it to:

WellSense Health Plan:

• Phone: Customer Care Center at 1-877-957-1300 or
• Fraud Hotline: 1-888-411-4959
• Email: FraudandAbuse@wellsense.org
• FAX: 1-866-750-0947
• Mail:
  Well Sense Health Plan
  Attn: Special Investigations Unit
  1155 Elm Street, 5th Floor
  Manchester, NH 03101

• Phone: 603-271-8029
• Toll Free (NH Residents): 800-852-3345, ext. 8029
• FAX: 603-271-8113
• Mail:
  Department of Health and Human Services
  Office of Improvement and Integrity, Program Integrity Unit
  129 Pleasant St., Thayer Building
  Concord, NH 03301

The Plan treats all information associated with a case as confidential; it is shared only with individuals who have a legitimate need to receive it. Such individuals may include the Plan Compliance Officer, legal department, and/or senior management and, in certain circumstances, state or federal agencies. If you prefer, you may report suspected fraud, waste or abuse anonymously.

Well Sense Health Plan’s Commitment

WellSense (the Plan) is committed to the stewardship of the State and Federal dollars that fund our program. This commitment requires that we ensure that the health care services provided to eligible members are done so by providers entitled to participate in federal programs, are medically necessary, meet certain quality requirements, are provided in a cost effective manner, are billed appropriately, and are paid according to contract terms and Plan policies. To that end, the Plan, in the course of normal operations, works to prevent fraud, waste and abuse (FWA) and to detect and correct any instances of FWA.

Why is Fraud, Waste and Abuse an Issue?

Studies by a variety of federal agencies and private organizations estimated the cost of fraud, waste and abuse in the healthcare industry, including federal programs, to be in the tens of billions of dollars a year. The resulting increase in the cost of health care affects all of us---all providers, health care recipients, and health plan, not only the small percentage of individuals who engage in it.

What are Fraud, Waste and Abuse?

• Fraud is generally defined as intentionally making, or attempting to make a false claim, representation or promise in an effort to receive payment or property to which one is not entitled.
• Abuse refers to actions or inactions that are inconsistent with sound fiscal, business or medical practices, and that result in unnecessary cost to the Plan.
• Waste generally means over-use of services or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources.

Fraud, waste and abuse in the healthcare industry may be perpetrated by providers, members, employees or vendors/contractors.

Examples of PROVIDER Fraud, Waste and Abuse include, but are not limited to:

• Providing services that are not medically necessary, given a member’s medical history;
• Falsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary or otherwise misrepresenting treatments as medically necessary for purposes of obtaining payment;
• Rendering services that fail to meet professionally recognized standards;
• Failing to accurately document services provided, including review of ordered tests;
• Billing for more expensive services or procedures than were actually provided or performed (i.e., "upcoding");
• Billing each step of a procedure as if it were a separate procedure (i.e., “unbundling”);
• Billing for services that were never rendered-either by using genuine patient information to fabricate entire claims or by padding claims with charges for procedures or services that did not take place;
• Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of the member’s health plan or by waiving patient co-pays or deductibles; and
• Accepting kickbacks for patient referrals.

Examples of MEMBER Fraud, Waste, and Abuse include, but are not limited to:

• Providing false information when applying for coverage;
• Sharing their Plan ID card with someone else or using another’s ID card;
• Doctor shopping;
• Diverting medications, equipment or supplies to others; and
• Using transportation benefits for non-medical reasons.

How Is Fraud, Waste and Abuse Identified?

The Plan’s Special Investigation Unit (SIU) receives referrals regarding suspicious behavior from multiple internal and external sources, including an anonymous hotline. In addition, the SIU staff utilizes a variety of software tools to both help find and prevent health care fraud both prior to and after claim payment. These tools employ rules that are consistent with provider contracts, Plan clinical and reimbursement policies, and Current Procedural Terminology (CPT)®, Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases coding guidelines.

What Do We Do When Fraud, Waste or Abuse Is Suspected?

Upon receipt of referrals and/or identification of outliers, the SIU instigates an investigation, which may include:

• Requesting and reviewing medical or other healthcare records for the purpose of verifying that billed services were provided and were coded correctly.
• Interviewing internal and external stakeholders, including provider(s), member(s), vendor(s), and/or others, to gather information pertinent to the case.
• Consulting state agencies, up to and including the state Medicaid office, Medicaid Fraud Control Unit and/or Attorney General’s Office.