Reporting Fraud, Waste and Abuse
Knowing Your Rights
what is neglect?
what is abuse?
Abuse means causing any physical, sexual or mental injury to you. This can also be taking advantage of your financial resources.
- Physical abuse. Any inappropriate contact that causes bodily harm. For example, being slapped, scratched, or pushed. Being threatened with a weapon, such as a knife or a gun, is another example.
- Sexual abuse. Any sexual behavior or intimate physical contact that occurs without your permission. This can be touching your genital area, buttocks or breasts.
- Mental abuse. When you feel emotional distress resulting from the use of demeaning or threatening words. This can also include signs, gestures and other actions. For example, controlling behavior, embarrassment or social isolation are types of mental abuse.
- Financial Abuse. When someone uses your money without your consent. This includes improper use of guardianship or power of attorney.
what is fraud?
“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 healthcare 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)
what can you do about healthcare fraud?
Sunshine Health 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:
1301 International Parkway
Sunrise, FL 33323
To report suspected fraud and/or abuse in Florida Medicaid, call the Consumer Complaint Hotline toll-free at 1-888-419-3456 or complete a Medicaid Fraud and Abuse Complaint Form, which is available online at: https://apps.ahca.myflorida.com/InspectorGeneral/fraud_complaintform.aspx
Or you can call Sunshine Health's 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 Sunshine Health resources. This could include things like:
- Loaning, selling or giving your Sunshine Health member ID card or Medicaid ID card to someone.
- Misusing Sunshine Health or Medicaid benefits.
- Billing Sunshine Health for “free” services.
- Wrongful billing to Sunshine Health by a provider.
- Billing Sunshine Health for services not provided.
- Any action to defraud Sunshine Health, Medicaid, or the AHCA program.
Attn: Medicaid Fraud Division
107 West Gaines Street
Tallahassee, FL 32301
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