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Report Fraud, Waste and Abuse

Fraud, Waste and Abuse (FWA) System

NH Healthy Families takes the detection, investigation, and prosecution of fraud, waste and abuse very seriously, and has a Fraud, Waste and Abuse (FWA) program that complies with New Hampshire and federal laws. NH Healthy Families, in conjunction with its management company, Centene, successfully operates a fraud, waste and abuse unit. NH Healthy Families performs front and back end audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system; please review the Billing and Claims section of the Provider Manual.

The Special Investigation Unit (SIU) performs prospective and retrospective audits which, in some cases, may result in taking actions against those providers, individually or as a practice, commit waste, abuse, and/or fraud.

These actions include but are not limited to:

  • Remedial education and/or training to prevent the billing irregularity
  • More stringent utilization review
  • Recoupment of previously paid monies
  • Termination of provider agreement or other contractual arrangement
  • Civil and/or criminal prosecution
  • Any other remedies available to rectify

Some of the most common FWA practices include:

  • Unbundling of codes
  • Up-coding services
  • Add-on codes billed without primary CPT
  • Diagnosis and/or procedure code not consistent with the member’s age/gender
  • Use of exclusion codes
  • Excessive use of units
  • Misuse of Benefits
  • Claims for services not rendered

If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our anonymous and confidential FWA hotline at 1-866-685-8664 or OIG’s Hotline at 800-HHS-TIPS (1-800-447-8477). NH Healthy Families and Centene take all reports of potential waste, abuse or fraud very seriously and investigate all reported issues.

Please Note: Due to the evolving nature of wasteful, abusive and fraudulent billing, NH Healthy Families and Centene may enhance the FWA program at any time. These enhancements may include but are not limited to creating, customizing or modifying claim edits, and upgrading software, modifying forensic analysis techniques, or adding new subcontractors to help in the detection of inconsistent billing patterns.