Fight Fraud, Waste & Abuse

Health care resources are precious and limited. Let's ensure they are devoted to meeting genuine health needs.

Are you concerned that you may have seen fraud, waste, or abuse of health care services or funding?

Is there an aspect of this topic we could better address in our provider training or news service?

Definitions

Fraud: When someone makes a false statement, false claim or false representation to UCare where the person knows or should reasonably know the statement, claim or representation is false; and where the false statement, claim or representation could result in an unauthorized benefit to the person or some other person.

Waste: Any over-utilization of services and misuse of resources that is not caused by fraud or abuse.

Abuse: A pattern of practice that is inconsistent with sound fiscal, business or medical practices and either directly or indirectly result in unnecessary costs to UCare, or that fail to meet professionally recognized standards for health care; enrollee practices that result in unnecessary cost to UCare; substantial failure to provide medically necessary items and services that are required to be provided to an enrollee if the failure has adversely affected or has a substantial likelihood of adversely affecting the health of the enrollee

Reach Out to UCare

Contact our Special Investigation team if you have any questions regarding fraud, waste and abuse, or if you suspect fraudulent, abusive or wasteful conditions.

Respond to Investigators' Requests

Our Investigators work diligently to detect and investigate allegations of fraud, waste, and abuse.

From time to time, UCare’s fraud Investigators may request health records or contact you to conduct an interview to verify services. In order for providers to seek claim payment from UCare, providers must document and retain each health service occurrence in the member’s health record. Providers are required to cooperate with UCare’s audit or investigation, consistent with your UCare contract provisions, UCare policy and applicable laws. Failure to cooperate may result in claim payments being denied or recovered by UCare.

Please join us in this important effort to avoid wasted health care dollars and potential harm to patients. We ask you to give a timely and complete response to an Investigator’s request. Your response can help to eliminate cases that should not be investigated, and keep investigators focused on the genuine cases that cause fraud, waste and abuse in the healthcare system.