Ways to Report Potential Fraud, Waste, and Abuse: Healthcare Compliance Guide

Use this Healthcare Compliance Guide to navigate Healthcare Fraud and Abuse Reporting across federal, state, and health plan channels. You will learn where to report, what to include, and how to follow Compliance Hotline Protocols that protect Healthcare Program Integrity and support Fraud Waste Abuse Prevention.

Reporting to HHS Office of Inspector General

File Office of Inspector General Complaints when suspected misconduct involves Medicare, Medicaid, CHIP, HHS grants, or kickbacks. This channel is best for provider billing schemes, identity theft, or misuse of federal healthcare funds.

How to report

You can submit a detailed complaint through standard OIG channels such as online forms, hotlines, or mail. Choose whether to remain anonymous or provide contact details for follow-up, and attach any documentation that supports your allegation.

What to include

• Names, roles, and contact details of involved parties (provider, facility, beneficiary).
• Dates of service, claim numbers, procedure codes, and amounts billed/paid.
• A clear description of the scheme and why it appears fraudulent or abusive.
• Copies of EOBs, invoices, medical records excerpts, or messages that substantiate the concern.

After you submit

Retain your narrative and evidence in case investigators request more detail. OIG may share your complaint with other agencies when appropriate to advance the investigation.

Contacting State Medicaid Fraud Control Units

Use your state’s MFCU for Medicaid provider fraud, patient abuse or neglect in facilities, and misappropriation of patient funds. Understanding basic Medicaid Fraud Control Unit Procedures helps your report move faster.

How to report

Most MFCUs accept reports by phone and online portals. Provide specific facility names, NPI or license numbers if available, and explain whether the issue involves billing, quality of care, or resident harm.

What to include

• Patient identifiers (initials or member ID), dates, and locations.
• Claims detail showing upcoding, unbundling, phantom billing, or medically unnecessary services.
• Names of witnesses or staff who can corroborate the events.

Utilizing Health Share of Oregon Compliance Hotline

Report concerns about providers or services within Health Share of Oregon’s network through its Compliance Hotline. This is appropriate for suspected overbilling, kickbacks, or conflicts of interest tied to the coordinated care organization.

Compliance Hotline Protocols

Hotlines typically allow anonymous, 24/7 intake and provide a confirmation number. Offer concise facts—who, what, when, where, how—and include Health Share member IDs and claim details when known.

What to include

• Provider/facility name, tax ID or NPI if available, and service dates.
• Type of concern (fraud, waste, abuse), with examples (duplicate billing, falsified documentation).
• Any documents (EOBs, referrals, authorizations) that show discrepancies.

Reporting to L.A. Care Health Plan

Use L.A. Care’s reporting channels for issues involving its networks, benefits, or contractors. This includes questionable claims, improper inducements, or patterns of medically unnecessary care.

How to report

Submit through the plan’s compliance hotline or dedicated reporting form. If you prefer, request language assistance and specify whether you want to remain anonymous while still enabling investigator follow-up.

What to include

• Member ID, claim numbers, dates of service, and billed amounts.
• Provider location and names of involved staff.
• A concise narrative linking evidence to the suspected violation.

Reporting Procedures for Amida Care

Amida Care accepts reports related to its plan services, providers, and subcontractors. Focus on clear facts that demonstrate potential fraud, waste, or abuse within the plan’s network.

Steps to take

Use the compliance hotline or written submission method provided by the plan. Indicate whether you are a member, provider, or employee, and attach relevant documents that illustrate the billing or authorization pattern.

Documentation checklist

• Member identifiers, authorization numbers, and claim lines.
• Clinical notes or scheduling records that contradict billed services.
• Any prior complaints or corrective actions already attempted.

Guidelines for Pennsylvania Health & Wellness Reporting

Report suspected FWA tied to Pennsylvania Health & Wellness providers, services, or benefits. Your goal is to aid Healthcare Program Integrity by making a precise, evidence-based submission.

How to report

Use the plan’s hotline or reporting portal. If you have multiple examples, summarize each occurrence with dates, CPT/HCPCS codes, and amounts so investigators can trend the activity.

What to include

• Member ID, provider NPI, facility location, and rendering clinician.
• Explanation of why services were unnecessary, not rendered, or misrepresented.
• Supporting EOBs, referrals, and correspondence with the provider or plan.

Reporting Channels for The Health Plan

The Health Plan’s Special Investigations/Compliance teams review allegations across its products. Use this route when claims, authorizations, or benefit determinations involve its networks.

How to report

Submit via hotline or written report and include your relationship to the case. If you choose to remain anonymous, provide enough detail for independent verification.

Evidence to gather

• Claims data, appointment logs, or pharmacy records showing irregularities.
• Screenshots or emails that reflect pressure to upcode or alter documentation.
• Any corrective steps already requested and the provider’s response.

Florida Medicaid Fraud Reporting Process

In Florida, report provider fraud to state authorities tasked with Medicaid oversight and investigations. Eligibility-related concerns (e.g., false information to obtain benefits) should be routed to the appropriate state benefits agency.

Practical steps

Describe the conduct, list facilities and NPIs when known, and attach claims or pharmacy data. If resident harm is involved, note safety risks so triage can prioritize the case.

Tips for stronger submissions

• Organize examples chronologically with claim numbers and dollar amounts.
• Differentiate errors from intentional patterns (e.g., repeated unbundling).
• Avoid sharing full Social Security numbers—use member IDs where possible.

Arizona DES Fraud Reporting Methods

Arizona DES accepts reports about potential fraud in state-administered benefit programs (such as SNAP, TANF, or childcare). For healthcare eligibility issues connected to those programs, DES reporting may be appropriate.

How to report

Use available phone or online intake to describe the conduct and any cross-program links to healthcare coverage. For provider billing fraud, also consider the federal or health plan channels listed in this guide.

What to include

• Program type, participant identifiers, dates, and locations.
• Documents showing false statements or misuse of benefits.
• Names of witnesses or caseworkers who can verify facts.

Reporting to Humana Compliance Department

Report concerns involving Humana’s networks, claims, or pharmacy benefits to its Compliance Department. This is appropriate for suspected kickbacks, upcoding, formulary manipulation, or falsified prior authorizations.

How to report

Use hotline or written channels, indicate your role, and decide whether to remain anonymous. Provide concise timelines and cross-reference claim numbers to help investigators reconstruct events.

What to include

• Member IDs, prescribing/ordering provider information, and dispensing details.
• Comparisons between medical necessity documentation and services billed.
• Any internal policies or emails that appear to encourage noncompliance.

Reporting Medicare Fraud to CMS

Use CMS reporting when issues involve Medicare benefits, plan administration, or enrollment irregularities. Follow Medicare Fraud Reporting Requirements by tailoring your submission to Original Medicare, Medicare Advantage, or Part D specifics.

Submission guidance

For Original Medicare claims, gather your Medicare Beneficiary Identifier (MBI), dates of service, and EOB details. For Medicare Advantage or Part D, include plan name, contract number if known, and claim/authorization references.

Evidence checklist

• Itemized bill or EOB showing services billed versus services received.
• Provider identifiers (NPI, TIN) and service locations.
• Notes explaining why services appear unnecessary, not rendered, or misrepresented.

Conclusion

Choose the channel that matches the program involved, deliver a clear fact pattern, and attach verifiable documents. Thorough reporting strengthens Healthcare Program Integrity and accelerates Fraud Waste Abuse Prevention across federal, state, and plan partners.