Fraud, Waste and Abuse
The National Healthcare Anti-Fraud Association (NHCAA) estimates that tens of billions
of dollars are lost to healthcare fraud each year
See details in footnote1. The SilverScript
Fraud, Waste and Abuse Program is committed to administering an effective plan to
prevent and detect fraud, waste and abuse.
We will work diligently to investigate all allegations, correct known offenses,
recover lost funds and partner with federal and state agencies to prosecute violators
to the fullest extent of the law.
Fraud - an intentional deception or misrepresentation made with
the knowledge that the deception could result in an unauthorized benefit.
Waste - the over-utilization of resources; using more resources
or services than are necessary.
Abuse - activities that are inconsistent with typical practices
and result in:
- An unnecessary cost to the Medicare program
- Reimbursement for medically unnecessary services
- Failure to meet professionally recognized standards for health care
Common Types of Fraud, Waste and Abuse
The following are examples of common types of fraud, waste or abuse:
Inappropriate Billing Practices
- Billing for non-existent prescriptions.
- Billing multiple payers for the same prescription (except as required for coordination
of benefit transactions).
- Billing for brand when generics are dispensed.
- Billing for non-covered services.
- Billing for prescriptions that are filled but never picked up.
- Splitting prescriptions into smaller day supplies to receive additional dispensing
- Accepting or offering kickbacks or bribes.
Prescription Drug Shorting
- Pharmacy provides less than the prescribed quantity and intentionally does not inform
the patient but bills for the full amount (i.e., billing for 60 tablets, but only
Prescription Refill Errors
- Pharmacy provides incorrect number of refills prescribed by the prescriber.
Illegal Remuneration Schemes
- Pharmacy offers, pays or solicits bribes or kickbacks to influence persons to prescribe
different drugs or steer patients to pharmacies.
- Pharmacy waives copayments to entice members to use that store.
We review member utilization and activities and investigate potential fraudulent
behavior in order to take appropriate action, including:
Misuse of Member ID cards
- Lending or sharing a valid Member ID card with an ineligible member or non-member
to illegally receive a plan benefit.
Prescription Forging or Altering
- Altering a prescription to increase the quantity or number of refills.
- Creating a false prescription or altering a valid prescription to obtain drugs or
benefits not prescribed.
- Consulting a number of doctors for the purpose of inappropriately obtaining multiple
prescriptions for narcotics, painkillers or other drugs.
- Doctor shopping may be indicative of an underlying scheme, such as stockpiling or
resale of drugs on the black market.
Prescription Diversion and Inappropriate Use
- Obtaining prescription drugs from a provider, to give or sell to someone else.
- Inappropriate consumption or distribution of a beneficiary's medications by a caregiver
or anyone other than the beneficiary.
- Misrepresenting personal information such as identity, eligibility,
or medical condition to illegally receive a plan benefit.
Please report any unusual activity or suspected fraudulent behaviors, including:
- Receiving premium bills from a company or individual you do not recognize.
- Requesting upfront payment of premiums before enrollment.
Broker Agent Marketing Schemes
- Falsifying application data.
- Enrolling non-existent members.
- Enrolling members without their knowledge or consent.
- Selling non-existent policies or plans.
- Accepting or offering kickbacks or bribes to entice members to enroll.
- Falsely representing Medicare, the Social Security Administration or the Part D
Plan to obtain personal and/or financial information.
- Utilizing another person's Medicare ID card to obtain prescriptions.
Be on the lookout for Medicare Fraud
to view common Medicare enrollment fraud schemes and how to detect enrollment fraud.
What Can You Do To Protect Yourself?
- Always keep your Medicare number and Social Security card safe, just as you would
a credit card or bank account number.
- Never provide personal information to anyone until you are certain that the person
or product is approved by Medicare or SilverScript Insurance Company.
- Always review your Summary of Benefits (SB) or Explanation of Benefits (EOB). Check
to see that your EOB does not show prescription drugs you did not receive.
- Do not accept offers of money or gifts from providers for providing prescription
drug services or to share your Medicare or Social Security number.
- Educate yourself about the Medicare Prescription Drug Program.
Fraud, Waste and Abuse Contact Information
How to Report Suspicious or Fraudulent Activity to SilverScript Insurance Company
We encourage you to report all suspected fraudulent activities. All reports are
treated as confidential and will be investigated. Please include as much detail
as possible, including dates and times, names, address and specifics about alleged
fraud or abuse.
Members, to report suspected fraud, waste and abuse, you can contact us by:
- Phone: Call the Fraud, Waste and Abuse Hotline toll-free at: Phone Number1-888-277-4149 (TTY: TeleType Number 711),
24 hours a day, 7 days a week.
- Email: Send your email to Medicare.firstname.lastname@example.org.
* Please note that communication by unencrypted email presents a risk that personally identifiable information contained in such an email may be intercepted by unauthorized third parties. Please do not email personally identifiable information.
Any party with knowledge of or a concern regarding fraudulent activities can also
report through the CVS Caremark Ethics Line. You can contact the Ethics Line by:
- Phone: Call the Ethics Line toll-free at: Phone Number1-877-CVS-2040 (TTY: TeleType Number 711), 24 hours
a day, 7 days a week
- Email: Send your email to Ethics.BusinessConduct@cvs.com
*Please note that communication by unencrypted email presents a risk that personally identifiable information contained in such an email may be intercepted by unauthorized third parties. Please do not email personally identifiable information.
- Confidential Fax: Send your facsimile report to 1-847-559-3835
- Confidential mailing address: Send your hard copy report to: Chief
Compliance Officer, CVS Caremark, One CVS Drive, Woonsocket, RI 02895
For more information about Fraud, Waste and Abuse, visit
The National Healthcare Anti-Fraud Association (NHCAA). . Back