Reporting Fraud, Waste and Abuse

You trust that your doctor, caregiver or loved one will take care of you. You believe they will always have your best interests in mind. Sometimes, when someone helps take care of you, they can take advantage of you. It is important to recognize the signs of neglect, abuse and fraud. If this happens, it is important to report it. This allows you to be safe and get the care you need.
Neglect occurs when someone fails to provide or withholds the necessities of life from you. This includes food, clothing, shelter, or medical care.

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.

“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)

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:

Sunshine Health
Compliance Department
1301 International Parkway
Suite 400
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. 
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
850-414-3300 
 
Your health care benefits are given to you based on your eligibility for both Medicaid and AHCA program. You must not share your benefits with anyone. Sunshine Health’s network providers must also report any misuse of benefits to Sunshine Health. Sunshine Health must also report any misuse or wrongful use of benefits to Medicaid. If you misuse your benefits, you could lose them. Medicaid may also take legal action against you if you misuse your benefits.
 
If you think a doctor, a hospital, another Sunshine Health member, or another person is misusing the Medicaid or Sunshine Health resources, tell us right away. We will take action against anyone who does this. Sunshine Health will take your call about waste, abuse, and fraud seriously. Call Sunshine Health's (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