Fraud, Waste & Abuse Prevention

We have a zero-tolerance policy on Fraud, Waste, and Abuse (FWA), and everyone is responsible to make a difference. The FWA program is built around protecting our beneficiaries and we believe this ‘member-centric’ vision is paramount to our overall mission of helping and protecting people. We have designated primary responsibility for the FWA program to the Special Investigations Unit (SIU).

With national health care expenditures of $2.6 trillion and rising each year, comprising approximately 17.9% of our nation’s Gross Domestic Product (GDP), it is imperative we curb the estimated 3% to 10% of FWA that plagues our health care system. The Medicare program, at $525 billion spent in 2010, is unable to withstand the burden of unnecessary expenditure. We are honored to serve our state and federal partners, and we understand how vital our role is in making an impact and preserving the integrity of our health care system. The below chart shows the potential impact FWA has on our nation’s health care system.

As part of the overall Compliance and FWA program, the SIU maintains written policies and procedures and adheres to the Corporate Code of Ethics which articulates the organization’s commitment to comply with all applicable Federal and State standards, including measures to detect, correct, and prevent FWA. We recognize the importance of building the foundation of the Company FWA program around prevention versus post-payment recovery or a ‘pay and chase’ philosophy. We place great emphasis on leveraging real-time data, technology and staff intervention at an earlier stage in the entire health care cycle to reduce vulnerability, lack of transparency and impact to FWA. This serves as the cornerstone of our ability to protect our beneficiaries and the overall integrity of the health care system as a whole.

Reporting Health Care Fraud, Waste & Abuse

If you have a reason to believe Fraud, Waste or Abuse (FWA) may have been committed, please contact us immediately.

SIU Mission Statement

‘The mission of  Special Investigations Unit (SIU) is to protect the overall integrity of the healthcare system, as well as to protect UHCG members, providers, business partners and stakeholders by administering a comprehensive and effective anti-fraud plan to prevent, detect, investigate and resolve allegations of potential fraud, waste and abuse (FWA). The Company is committed to preventing and recovering dollars lost to FWA and partnering with state and federal law enforcement agencies to prosecute violators to the fullest extent of the law.’

Whistleblower Protection

The Civil False Claims Act also provides protection for employees from retaliation. An employee who is discharged, demoted, suspended, threatened, harassed, or discriminated against in terms and conditions of employment because of lawful acts conducted in furtherance of an action under the FCA may bring an action in federal district court seeking reinstatement, two times the amount of back pay plus interest, and other enumerated costs.

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