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Fraud, Waste & Abuse


What is Fraud?

An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person. It includes any act that constitutes Fraud under applicable Federal or Puerto Rico law.

You have the responsibility of reporting any situation you understand may involve fraud against the Medicaid program. Some examples of fraud are:

  • Billing for medical services or procedures not actually performed.
  • Billing for supplies or medications not dispensed.
  • Lending an ID card to someone who is not entitled to it (misrepresentation) to obtain clinical services or medications.
  • Billing for a more costly payment than the one actually performed to obtain a higher payment.
  • Submitting false documents to obtain reimbursements.
  • Billing for the same service more than once.
  • Billing for the dispensing of full Prescription when the Prescription was actually filled partially.
  • Receiving services rendered by a provider that has been excluded from the Medicaid Program.
  • Receiving reimbursement for services that are not medically necessary or that do not comply with the health care professional standards.

It is important that any illegal or fraudulent action be reported immediately to your Health Plan’s Complaint Unit, the Patient’s Advocate Office or to ASES at the telephone numbers listed in section How can I report situations on Fraud, Waste and/or Abuse?, below.

What is Abuse?

Abuse is when the Provider practices that are inconsistent with sound fiscal, business, or medical practices, and that result in unnecessary costs to the Government Health Program or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for the provision of health care. It also includes Enrollees practices that result in unnecessary costs to the Government Health Plan of Puerto Rico.

Some examples are:

  • Overuse of services that are not medically necessary, such as constantly using the emergency room instead of going to the PCP.
  • Excess in the orders for diagnostic tests that do not have a medical justification.
  • Waiving health plan Co-payments or Co-insurances to attract customers.

What is Waste?

Waste is a health care spending that can be eliminated without reducing quality of care. Some examples are:

  • Prescribing high cost medications instead of similar generic or lower cost medication.
  • Billing errors due to inefficient billing systems.
  • Inflated prices on services or devices.

You can also help prevent fraud and abuse. Here are some things you can do:

  • Don’t give your ID card to anyone else.
  • Learn about your Vital benefits.
  • Keep records of your doctor’s visits, laboratory tests and medications. Make sure you don’t get repeat services.
  • Make sure your information is right on a form before you sign it.
  • Request and review the quarterly summary of the services you receive. You may request the summary of services directly from First Medical.

How can I report situations on Fraud, Waste and/or Abuse?

If you have information or suspicion that you have been a victim of health plan fraud, you may contact First Medical or Vital Call Center at the numbers that appear on the back of your ID card, by fax at 787-300-3913, by email at alertafraude@firstmedicalpr.com, by visiting First Medical Customer Service Centers or by mail at:

First Medical Health Plan, Inc.
Unidad de Investigaciones Especiales
PO Box 191580
San Juan, PR 00919-1580

You may also contact the Health Advocate Office at 787-977-0909 or, Vital Call Center at 1-800-981-2737 or by visiting the Health Advocate Office or ASES Offices.

For more information on this matter you can access the orientation on Fraud, Waste and Abuse section on the ASES website at www.ases.pr.gov. From this section of the website you can download the incident referral document which you can use to report any situation on Fraud, Waste and/or Abuse. Additionally, this section contains the contact information of all the agencies you can call to report any situation on Fraud, Waste and/or Abuse. Upon completing ASES’s incident referral document, you have the option of indicating that you do not want to be contacted and/or remain anonymous.

Your call or written communication will be handled confidentially and your coverage with the Government Health Plan of Puerto Rico will not be affected by this referral. If the investigation shows that Fraud, Waste or Abuse was committed, the case will be referred to the corresponding authorities.