Fraud, Waste and Abuse
Health care resources are precious and limited. Help ensure they are devoted to meeting genuine health needs.
Are you concerned that you may have seen fraud, waste or abuse of health care services or funding?
Is there an aspect of this topic we could better address in our Medicare Advantage Provider Newsletter?
Fraud: When someone makes a false statement, false claim or false representation to Aspirus Health Plan where the person knows or should reasonably know the statement, claim or representation is false; and where the false statement, claim or representation could result in an unauthorized benefit to the person or some other person.
Waste: Any over-utilization of services and misuse of resources that is not caused by fraud or abuse.
Abuse: A pattern of practice that is inconsistent with sound fiscal, business or medical practices and either directly or indirectly result in unnecessary costs to Aspirus Health Plan, or that fail to meet professionally recognized standards for health care; enrollee practices that result in unnecessary cost to Aspirus Health Plan; substantial failure to provide medically necessary items and services that are required to be provided to an enrollee if the failure has adversely affected or has a substantial likelihood of adversely affecting the health of the enrollee.
Reach Out to Aspirus Health Plan
Contact our Special Investigation team if you have any questions regarding fraud, waste and abuse, or if you suspect fraudulent, abusive or wasteful conditions related to our Medicare Advantage plans.
Call our toll-free helpline. You may remain anonymous. If we are unavailable when you call, please leave a message.
Send us a letter and/or documents you would like us to review.
Aspirus Health Plan
Attn: Special Investigation Unit
P.O. Box 51
Minneapolis, MN 55440
Send us an email message with your question or concern.
Respond to Investigators' Requests
Our Investigators work diligently to detect and investigate allegations of fraud, waste and abuse.
From time to time, Aspirus Health Plan’s fraud Investigators may request health records or contact you to conduct an interview to verify services. In order for providers to seek claim payment from Aspirus Health Plan, providers must document and retain each health service occurrence in the member’s health record. Providers are required to cooperate with Aspirus Health Plan’s audit or investigation, consistent with your Aspirus Health Plan contract provisions, Aspirus Health Plan policy and applicable laws. Failure to cooperate may result in claim payments being denied or recovered by Aspirus Health Plan.
Please join us in this important effort to avoid wasted health care dollars and potential harm to patients. We ask you to give a timely and complete response to an Investigator’s request. Your response can help to eliminate cases that should not be investigated, and keep investigators focused on the genuine cases that cause fraud, waste and abuse in the healthcare system.