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Fraud, waste, and abuse

Fraud, waste, and abuse

Doing the right thing

As a community health plan that values partnership, service excellence, and relationships, we are committed to doing the right thing. We have Compliance and Fraud, Waste, and Abuse (FWA) programs that we follow to ensure we comply with State and Federal laws, regulations, and our internal policies and procedures.

How to report healthcare fraud

We’re committed to combating healthcare fraud that can drive up costs and put a burden on taxpayers and the healthcare system. If you suspect healthcare fraud, please report it and we will work with State and Federal government agencies to investigate your concerns.

Call us

800-431-4135, TTY: 711.
We accept all relay calls.

Submit an anonymous report

Contact EthicsPoint, a PacificSource vendor, 24/7.
Call: 888-265-4068
Submit: Report online

Identifying healthcare fraud

If you suspect an activity is fraudulent, but aren’t sure, the following scenarios can serve as examples of what you should look for.

 

Provider FWA

  • A provider charging you for a service covered by PacificSource Community Solutions
  • A provider billing for services that you did not receive
  • A provider giving you a service that you do not need based on your health condition

Member FWA

  • Going to multiple doctors for prescriptions for a drug already prescribed to you
  • Someone using another person’s ID to get benefits

Compliance and FWA programs 

Our programs allow us to carry out the activities needed to support our culture of compliance. The programs include important topics such as:

  • Training and education
  • Code of Conduct
  • Policies and procedures
  • Compliance Officer and Compliance Committee
  • Monitoring and auditing
  • How to report issues
  • How we look into and resolve issues
  • How we correct issues

  

Resources to protect yourself

Below are documents and websites with tips and important information on how to protect yourself against fraudulent activities. This includes how to spot fraud and how to report your concerns.