Vantage Health Plan, Inc.'s Fraud, Waste & Abuse Policy

Prevention and Detection of Fraud, Waste, and Abuse

Vantage is dedicated to improving healthcare. Vantage's efforts to detect and prevent insurance fraud, waste, and abuse ("FWA") are important in maintaining the level of service provided to our members.

FWA can cause premium increases, and even the reduction or termination of some benefits. We believe that early detection and proactive prevention of FWA, through Vantage's efforts and the efforts of our members and providers, will limit the negative impact of FWA on the healthcare system and those who access its services.

Fraud, Waste, and Abuse Program

Vantage has developed a Fraud, Waste, and Abuse Program to serve as a guide to assist those associated with Vantage in preventing, detecting, investigating, and helping correct conduct which is considered to be fraudulent, wasteful, and/or abusive.

What is Fraud, Waste, and Abuse?

Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to the person or others.

Examples of fraud:

  • Billing for services or durable medical equipment that was never provided
  • Billing for the same service multiple times
  • Tampering with claims details
  • Identity Theft
  • Incorrect coding
  • Misrepresentation of a member's medical condition (past and present)
  • Prescription Forging
  • Soliciting, offering, or receiving a kickback or bribe

Waste and Abuse can be viewed as spending that can be reduced without impacting the quality of care received by the member.

Examples of waste and abuse:

  • Prescribing medication for 30 days with a refill when it is not known if the medication will be needed
  • Performing and billing an insurance company for laboratory work that is not necessary
Reporting Fraud, Waste, and Abuse

You can help! If you suspect fraud by a provider or member, please report it to Vantage for investigation. All correspondence is confidential.