• What is Fraud?
  • What is Abuse?
  • What is Waste?
  • What can I do to avoid Fraud, Waste and Abuse?
  • How can I report situations on Fraud, Waste and/or Abuse?
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    What is Fraud?

    Fraud affects adversely insured beneficiaries, health plans and professionals and entities that render health services. Fraud refers to any intentional and deliberate act to deprive another of property or money through deception or any other unfair action. It is done with the purpose of deceiving or making false misrepresentation with the purpose of obtaining a personal benefit or to benefit another person.

    You have the responsibility of reporting any situation you understand may involve fraud against the Medicaid Program. Some examples of fraud are:

    • Billing for medical services or procedures not actually performed.
    • Billing for supplies or medications not dispensed.
    • Lending an ID card to someone who is not entitled to it (misrepresentation) to obtain clinical services or medications.
    • Billing for a more costly payment than the one actually performed to obtain a higher payment.
    • Submitting false documents to obtain reimbursements.
    • Billing for the same service more than once.
    • Providing false information in a health enrollment form.
    • Billing for the dispensing of full Prescription when the Prescription was actually filled partially.
    • Receiving services rendered by a provider that has been excluded from the Medicaid Program.
    • Receiving reimbursement for services that are not medically necessary or that do not comply with the health care professional standards.

     

    It is important that any illegal or fraudulent action be reported immediately to your Health Plan’s Complaint Unit, the Patient’s Advocate Office or to ASES at the telephone numbers or email addresses included in page 5 of the Enrollee Manual.

     

     
     

    Enrollee Services
    1-844-336-3331 (toll free)
    787-999-4411 TTY (hearing impaired)
    Monday through Friday
    from 7:00 a.m. to 7:00 p.m.

    Postal Address
    PO BOX 72010
    San Juan, PR 00936-7710

    Physical Address
    Fundación Ángel Ramos 
    Ave. Chardón  
    Hato Rey, PR

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