Fraud and Abuse Concerns
Fraud is knowingly and willfully executing, or attempting to execute, a scheme to obtain financial or personal gain. (Example: billing for services not provided) The term does not include unintentional technical, clerical, or administrative errors.
Abuse is any action that may 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 and services that not medically necessary. (Example: billing excessive charges for services or supplies)
Fraud Protection and Prevention
FirstCare Health Plans Special Investigations Unit (SIU) utilizes fraud detection software for medical and prescription claims, investigates any suspicious claims and reviews concerns from members and other sources regarding possible fraud and abuse.
Common concerns from members are suspicious phone calls and bills for services not received.
Suspicious Phone Calls
Example: You receive a call from someone claiming to be from FirstCare Health Plans and they ask for personal information like your social security number or financial information.
If you suspect a call may be a scam, do not give any personal or financial information.
Here are a few ways you can protect yourself against future calls:
Bills for Services You Did Not Receive
Example: You see a service on your Explanation of Benefits (EOB) or get a bill for something you did not receive.
If you receive a bill for services you do not recognize, it is best to contact your provider first. It may be a simple error that can be easily corrected. If you still suspect fraudulent activity after speaking with your provider, you can contact the FirstCare Health Plans using one of the following:
FirstCare Health Plans Helpline
The helpline is a confidential means of reporting.
FirstCare Health Plans Compliance Officer
| Phone: |
1-214-820-8888 |
| Mail: |
FirstCare Health Plans
Compliance Department
1206 W Campus Drive
Temple, TX 76502
|
| Fax: |
1-254-298-3508 |
You may also contact the Texas Department of Insurance (TDI) using one of the following:
Here are a few ways you can identify services billed to the Health Plan:
- Review your monthly Health Plan Explanation of Benefits (EOB) to ensure accurate dates of service, name of providers, and services billed.
- Use the MyBSWHealth app: App Store and Google Play.
Potential Schemes Related to COVID-19
Scammers are using telemarketing, text messages, door-to-door visits as well as social media to conduct their fraudulent activities. These individuals are offering COVID-19 tests, grants and prescription cards in exchange for personal information to benefit themselves and harm the public.
Ways to protect yourself from fraud and abuse schemes:
- Never share information to unknown individuals. This should include date of birth, social security number, Medicaid or Medicare numbers, health care details, financial or other personal identifiable information. Sharing this type of information can lead to identity theft.
- Review your explanation of benefits (EOB) or MyBSWHealth for suspicious activity or claims.
- Ignore offers or advertisements for COVID-19 testing or treatments on social media.
- Never post photos of your COVID-19 vaccination cards on social media.
- Do not open links in text messages from unknown individuals.
- Do not trust any unexpected calls or visitors offering COVID-19 tests or supplies.
- Do not pay anyone to speed up your vaccine eligibility.
- Report suspected fraud to health plan helpline: 1-866-399-8161