As part of our efforts to improve the healthcare system in Maine and offer affordable health insurance plans to our Members, Community Health Options® has made a commitment to detecting, investigating, correcting, and preventing fraud, waste, and abuse.
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain any of the money or property owned by, or under the custody or control of, any health care benefit program. (18 U.S.C. § 1347)
Examples of Health Care Provider Fraud are (but not limited to):
Examples of Health Care Member Fraud are (but not limited to):
Waste is the overutilization of services resulting in unnecessary costs to the health care system.
Abuse is payment for items or services when there is no legal entitlement to that payment and the health care provider billing Community Health Options has not knowingly and/or intentionally misrepresented facts in order to obtain payment. Abuse includes any action that may result in unnecessary costs to the health care system, improper payment for services, or services that are not medically necessary.
Please notify Community Health Options if you suspect healthcare fraud, waste, or abuse has taken place by using the following resources:
All information received is strictly confidential. As specified under the HIPAA regulation, section 164.512 (f), Community Health Options may make referrals to law enforcement agencies for further investigation.
Community Health Options' Fraud Waste and Abuse team will begin researching materials such as claims records. After the claims records have been reviewed, a member of Community Health Options’ team may request relevant medical documentation from the parties involved. All materials are then analyzed before a final determination is made.