Report Fraud, Waste and Abuse (Medicaid)
Children's Medical Services (CMS) Health Plan is serious about finding and reporting times that Florida Medicaid funds are used in the wrong way. This is called waste, fraud or abuse.
Fraud means to knowingly get benefits or payments that you are not entitled to receive. Please let us know if you are aware of someone who is committing fraud. This could be a provider or a member. Some examples of health care fraud include:
- A lie on an application
- Using someone else's ID card
- A provider (doctor) billing for services that were not done
- Transportation (usage abuse)
Waste is the overuse of services that may result in costs not needed for healthcare benefits. This includes direct costs and indirect costs. Waste usually results from the misuse of services.
Abuse is actions that may result in unnecessary costs not needed for health care benefits. This includes direct costs and indirect costs. Abuse involves payment for items or services when there is no legal reason for to pay for them.
CMS Health Plan is serious about finding and reporting fraud and abuse. Our staff is available to talk to you about this. Here are the address and phone numbers:
Children’s Medical Service’s Health Plan
P.O. Box 459089
Fort Lauderdale, FL 33345-9089
Or you can call CMS Health Plan WAF Hotline at 1-866-685-8664.
Waste, abuse, and fraud means that any member, any provider, or another person is misusing Medicaid, the AHCA program, or CMS Health Plan resources. This could include things like:
- Loaning, selling or giving a CMS Health Plan member ID card or Medicaid ID card to someone.
- Misusing CMS Health Plan or Medicaid benefits.
- Billing CMS Health Plan for “free” services.
- Wrongful billing to CMS Health Plan by a provider.
- Billing CMS Health Plan for services not provided.
- Any action to defraud CMS Health Plan, Medicaid or the AHCA program.
If you report suspected fraud and your report results in a fine, penalty or forfeiture of property from a doctor or other health care provider, you may be eligible for a reward through the Attorney General’s Fraud Rewards Program (toll-free 1-866-966-7226 or 850-414-3990). The reward may be up to 25% of the amount recovered, or a maximum of $500,000 per case (Section 409.9203, Florida Statutes). You can talk to the Attorney General’s Office about keeping your identity confidential and protected. Medicaid’s address and phone number are:
Florida Attorney General’s Office
Attn: Medicaid Fraud Division
107 West Gaines Street
Tallahassee, FL 32301
Your child's healthcare benefits are given based on eligibility for both Medicaid and AHCA program. You must not share your child's benefits with anyone. CMS Health Plan's network providers must also report any misuse of benefits to CMS Health Plan. CMS Health Plan must also report any misuse or wrongful use of benefits to Medicaid. If you misuse your chid's benefits, your child could lose them. Medicaid may also take legal action against you if you misuse your child's benefits.
If you think a doctor, a hospital, another CMS Health Plan member, or another person is misusing the Medicaid or CMS Health Plan resources, tell us right away. We will take action against anyone who does this. CMS Health Plan will take your call about waste, abuse and fraud seriously. Call CMS Health Plan (Waste, Fraud, and Abuse) WAF Hotline at 1-866-685-8664. You do not need to give your name.
To report waste, abuse or fraud, gather as much information as possible.
When reporting about a provider (a doctor, dentist, counselor, etc.) include:
- Name, address, and phone number of provider
- Name and address of the facility (hospital, nursing home, home health agency, etc.)
- Medicaid number of the provider and facility, if you have it
- Type of provider (doctor, dentist, therapist, pharmacist, etc.)
- Names and phone numbers of other witnesses who can help in the investigation
- Dates of events
- Summary of what happened
When reporting about someone who gets benefits, include:
- The person’s name
- The person’s date of birth, Social Security Number, or case number if you have it
- The city where the person lives
- Specific details about the waste, abuse, or fraud
Potential Fraud, Waste or Abuse reporting may be called to CMS Health Plan's anonymous and confidential hotline at 1-866-685-8664 or by contacting the Compliance Officer at 1-866-796-0530. You may also send an email to Compliancefl@centene.com
To report suspected fraud, waste, abuse or neglect in the Medicaid, Long Term Care or Florida Healthy Kids programs, please use one of the following avenues:
- AHCA Consumer Complaint Hotline: 1-888-419-3456
- Florida Attorney General’s Office: 1-866-966-7226
- The Florida Medicaid Program Integrity Office: 1-850-412-4600
- Agency for Health Care Administration (AHCA) Medicaid Fraud and Abuse Complaint Form
- Report Insurance Fraud to Florida's Chief Financial Officer
- Fraud, Waste and Abuse Referral Form - English (PDF)
- Fraud, Waste and Abuse Referral Form - Spanish (PDF)