FRAUD, WASTE & ABUSE

AlohaCare wants to ensure that we are all working together to protect the resources available to serve our members. Health care fraud, waste and abuse (FWA) hurts everyone including members, providers, and taxpayers. AlohaCare is committed to protecting the integrity of the healthcare system in the fight against FWA by preventing, detecting and correcting instances of FWA. Please help us by reporting questionable activities you believe could be potential FWA.

Provider Fraud, Waste & Abuse

Some examples of provider activity that is monitored for fraud, waste and abuse:

• Prescribing drugs, equipment or services that are not medically necessary
• Billing more than once for the same service
• Intentionally using improper medical coding to receive a higher rate of reimbursement
• Billing for services not provided
• Scheduling more frequent return visits than are needed
• Unbundling services to obtain higher reimbursement
• Purchasing drugs from outside the U.S.
• Prescribing high quantities of controlled substances without medical necessity

Member Fraud, Waste & Abuse

AlohaCare monitors member activity for fraud, waste and abuse. Some examples are:

• Inappropriately using services such as selling prescribed narcotics, or seeking controlled substances from multiple providers or multiple pharmacies
• Sharing a member ID card
• Obtaining unnecessary equipment/supplies
• Changing prescription forms to get more than the amount of medication prescribed by their physician
• Member receiving services or picking up prescriptions under another person's ID (identity theft)

Pharmacy Fraud, Waste & Abuse

Examples of pharmacy fraud, waste and abuse:

• Prescription drugs not dispensed as written
• Submitting claims for a more expensive brand name drug when a less expensive generic prescription is dispensed
• Dispensing less than the prescribed quantity without arranging for the additional medication to be received with no additional dispensing fees
• Splitting prescriptions into two orders to seek higher reimbursement
• Dispensing expired, fake, diluted or illegal drugs
• Billing for prescriptions not filled or picked up

Report Fraud, Waste & Abuse

• Options that are anonymous:
  • Call our 24/7 hotline at 855-973-1852
  • Write to us or use our FWA Reporting Form and mail to:
    AlohaCare
    ATTN: Special Investigations Unit
    1357 Kapiolani Blvd,
    Suite G101
    Honolulu, HI 96814

• Options that are not anonymous:
  • Email us at fraud@alohacare.org
  • Contact customer service toll-free at 1-800-434-1002
  • Fax: 808-973-7410
  • Report to your assigned AlohaCare Provider Representative

• When reporting, please give a detailed description of the activity, including:
  • Name and contact info of person believed to be committing FWA
  • Date of suspicious activity
  • Issue of concern and any other pertinent information
  • Your contact info, if anonymity is not requested
  Note: You may report anonymously, however if you do not provide your identity, we will not be able to contact you for more information, if needed.