Compliance, Fraud, Waste & Abuse

Corporate Compliance

The importance of integrity, ethics, and compliance is emphasized among Common Ground Healthcare Cooperative (CGHC) employees and is reinforced through our Compliance Program and Compliance and Integrity Code of Conduct.

Review each of our documents here:

• • • Compliance Program
    • Compliance and Integrity Code of Conduct

Fraud, Waste & Abuse

CGHC has a program designed to handle cases of health care fraud. Providers or members can commit fraud. We monitor and take action on any member or provider fraud, waste and abuse. Some examples are:

Provider Fraud, Waste and Abuse

• • • Prescribing drugs, equipment or services that are not medically necessary.
    • Scheduling more frequent return visits than are medically necessary.
    • Billing for tests or services not provided to a member.
    • Billing for more expensive services than provided.

Member Fraud, Waste and Abuse

• • • Sharing or misusing a CGHC ID card with another person.
    • Selling prescribed drugs or other medical equipment paid for by CGHC to others.
    • Submitting false information.
    • Forging a doctor’s signature on prescriptions, etc.
    • Providing inaccurate symptoms and other information to providers to get treatment, drugs, etc.

Pharmacy Fraud, Waste and Abuse

• • • Providing drugs that are not according to the prescription.
    • Providing a generic drug then sending in a claim for a more expensive brand-name drug.
    • Giving a member less than the prescribed drug amount without telling the member and without giving the rest of the amount the member should receive.

Do You Suspect Fraud, Waste or Abuse?

If you think a provider or a CGHC member is committing fraud, waste or abuse, you can report your concerns to us by:

• • • Contacting the Confidential Compliance Hotline using one of the following methods:
      • Phone: (855) 358-3898
      • Email: CommonGroundHealthcare@GetInTouch.com
      • Web Form: lighthouse-services.com/commongroundhealthcare

You can choose to remain anonymous when you contact the hotline. If you choose to remain anonymous, you may receive or create a 4-digit PIN (letters/numbers) that will allow you to have anonymous dialog with CGHC through our confidential hotline vendor.

When you report fraud, waste or abuse, please give us detailed information that includes a clear description of what you believe has happened. Please also give us the names and phone numbers of those involved if you have them. Please leave as many details as possible. Your report will be kept confidential to the extent permitted by law.

How Can Members Protect Against Fraud?

Below are a few simple tips to help members protect against health care fraud:

• • • Treat the member ID card like you would a credit card. Don’t give out policy numbers to door-to-door salespeople, over the phone or on the internet. Watch out for people trying to offer you money or other free items for personal information.
    • Beware of any offers for free services or items (food, gas, gift cards, etc.) in exchange for a CGHC member ID number.
    • Do not sign your name to a blank form. If you have questions about what you are signing, be sure to ask a health partner you trust.
    • Read the Explanation of Benefit (EOB) statements and any papers you receive from CGHC. Are there any services, supplies or equipment listed that you did not receive? Are there any services that were billed more than once but you received only once? Did you get services on all the dates of service that are shown?

If you suspect an error or fraud, report it to CGHC using one of the methods above.

Thank you for helping CGHC keep fraud, waste and abuse out of health care.