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Fraud, Waste & Abuse


What is Fraud?

A deliberate act, intentional deception or manipulation made by a person with the knowledge that deception could result in some unauthorized benefit or financial gain for himself or another person.

It includes any act that constitutes Fraud under Federal or Puerto Rico laws.

You are responsible for reporting any situation that you understand may involve fraud against the Medicaid Program.

Examples of fraud include:

  • Billing for medical services and procedures not performed.
  • Billing for supplies or medicines not dispensed.
  • Give the health plan card to someone else for medical services or medications.
  • Bill for more expensive services that were provided for a higher payment.
  • Submit false documentation to obtain a refund for services not covered and/or services that are not medically necessary or that do not meet the standards of health professionals.
  • Bill for the same service more than once.
  • Receive services provided by a provider who has been excluded from the Medicaid Program.
  • Refunds for services that are not medically necessary or that do not meet the standards of healthcare professionals.

 

It is important that any illegal or fraudulent action be immediately reported to the Complaints Unit of your health plan, the Office of the Patient Attorney or ASES on the phone numbers found in the section below: How can I report a situation of Fraud, Waste and/or Abuse?

What is Abuse?

Abuse is inappropriate behavior. It occurs when the practices of the Supplier or beneficiary are inconsistent with tax, commercial or medical practices and result in an unnecessary cost to the Government Health Plan.

Examples include:

  • Excessive use of services that are not medically necessary, such as constant use of the emergency room that do not require emergency care.
  • 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?

Misuse means excessive use of services without medical need.

Examples include:

  • Prescribe high-cost drugs instead of a generic or lower-cost drug.
  • Billing errors due to inefficiencies in billing systems.
  • Increased prices on services or equipment.

 

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

  • Do not lend your health plan ID card to anyone.
  • Learn about your Vital benefits.
  • Keep a record of your doctor visits, lab tests, and medications.
  • Make sure you do not receive repeat services.
  • Make sure your information is correct in any form or document before signing it.
  • Request and review the quarterly summary of services received. You may request a summary of services directly with First Medical.

How can I report fraud, waste and/or abuse situations?

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

First Medical Health Plan, Inc.

Special Investigation Unit
PO Box 191580
San Juan, PR 00919-1580

You can also contact the Patient Attorney’s Office at 787-977-0909 or the Vital Call Center at 1-800-981-2737 or by visiting the Patient Attorney’s Office or ASES.

For more information on this topic, you can go to the guidance section under Fraud, Waste or Abuse on the ASES website at www.planvitalpr.com. In this section you can download the incident referral document which you can use to report any situation of Fraud, Waste and/or Abuse. In addition, this section contains contact information from all agencies that you may call to report any fraud, waste and/or abuse situations.  Once you complete the ASES referral, you have the option to indicate whether you do not want to be contacted and/or remain anonymous.

Your call or written communication will be treated confidentially and your coverage of the Health Plan of the Government of Puerto Rico, will not be affected by this reference.  If the investigation proves that fraud, waste, or abuse was committed, the case will refer to the relevant authorities.