Report Fraud, Waste and Abuse

Medicaid fraud and abuse

MHS Health is committed to identifying, investigating, sanctioning and prosecuting suspected fraud and abuse. Its fraud and abuse plan complies with the State of Wisconsin and federal laws.

Waste, Abuse, and Fraud (WAF) is an MHS Health initiative that systematically identifies, investigates and addresses instances where billing errors, abuse, or fraud occur. The WAF program complies with state and federal law, and DHS guidelines. All MHS Health staff are trained to identify possible waste, abuse and fraud.

Billing errors

Billing errors may occur if provider offices provide incorrect information on submitted claims. Provider Relations representatives will work with provider offices to correct these situations.

Abuse

Abuse involves billing errors that directly or indirectly lead to financial loss for MHS Health. Examples can include overcharging for services and billing for: an office visit and outpatient procedure the same day, unbundling charges, billing for non-covered services, diagnoses that are not adequately supported in the medical record, and medically inappropriate procedures and tests.

Fraud

Fraud is intentional deception or misrepresentation by patients, providers, billing services, or payer employees. Examples can include billing for services not rendered, misrepresenting diagnoses to justify payment, soliciting, offering or receiving a kickback, falsifying medical records to justify payment, and “up coding.”

How you can help

Providers are in the best position to identify potential member fraud as the most common incidence involves members sharing their ForwardHealth card with family members and friends. If you suspect this is happening, please call the MHS Health Compliance Officer at 1-800-222-9831.