Report Fraud, Waste and Abuse

FirstCarolinaCare Insurance Company (“FCC”) is committed to maintaining a culture that promotes the prevention, detection and resolution of issues or conduct that fails to adhere to its policies, procedures and Medicare rules and regulations

FCC requests that its employees, Medicare members, First Tier, Downstream and Related Entities (FDRs) and their employees and other vendors promptly report any suspected / actual instances of Fraud, Waste or Abuse (FWA) or any violation of Federal, State or Medicare rules to its Compliance Department.

To assist with this requirement, FCC’s Compliance Department has established a secure Compliance Helpline. This Helpline provides an avenue for callers to report any activity in a confidential manner. All calls to the Compliance Helpline are treated as private and there is no retaliation for any confidential calls made in good faith.

COMPLIANCE HELPLINE: (855) 367- 8184 (toll free)

If you are not comfortable with or unable to make a report via the Compliance Helpline, please send a written report by mail or email to:

Director of Compliance
FirstCarolinaCare Insurance Company
42 Memorial Drive
Pinehurst, NC 28374
compliance@firstcarolinacare.com

Fraud– It is defined by the Center for Medicare and Medicaid Services (CMS) as an intentional deception or misrepresentation made by an individual who knows that the false information reported could result in an unauthorized benefit to himself/herself or another person

Waste– Unintentional overuse or underuse of services that directly or indirectly result in unnecessary costs to the Medicare Program.

Abuse– includes any action(s) that may directly or indirectly result in unnecessary costs to the Medicare Advantage program including improper payment, payment for services not rendered, and payment for services that fail to meet professionally recognized standardized standards of care or services that are medically unnecessary.

  • Members
  • Pharmacies
  • Providers/ Prescribers and their employees
  • Agents/Brokers
  • Health Plans and their employees
  • FDRs and their employees
  • Suppliers of Durable Medical Equipment
  • Claims processing companies

Common types of fraudulent Medicare schemes include but are not limited to:

Member Fraud

  • Using another person’s Medicare card to obtain medical care
  • Medical identity theft
  • Filing false claims
  • Forging or altering enrollment forms or prescriptions
  • Resale of drugs on the black market
  • Misrepresentation of status or current coverage

Provider Fraud

  • Billing for care of a patient who was never seen or for services not performed
  • Billing for unnecessary services
  • Billing for extensive or complicated services than were actually delivered
  • Duplicate billing

Sales Agents/Broker Fraud

  • Altering/Destroying enrollment forms
  • Backdating enrollment forms prior to submission or instructing a prospective member to do so.
  • Submitting false enrollment information to a health plan for enrollment
  • Misrepresentation of plan benefits
  • Advising beneficiaries to enroll in a plan they do not need

Pharmacy Fraud

  • Billing for non-existent prescriptions
  • Billing for brand medications when generics are dispensed
  • Billing multiple payers for the same prescriptions, except as required for coordination of benefit transactions
  • Incorrectly billing for secondary payer to receive increased reimbursement
  • Dispensing expired or adulterated prescription drugs
  • Prescription refill errors
  • Illegal Remuneration Schemes
  • True-Out-of-Pocket (TrOOP) manipulation
  • Failure to offer negotiated Medicare Part D prices to members
  • Altering scripts or data to obtain a higher payment amount

Health Plan Fraud

  • Improper bid submissions
  • Failure to provide medically necessary services
  • Payment for excluded drugs
  • Improper member coordination of benefits
  • Improper enrollment/disenrollment activities
  • Multiple billing
  • Inappropriate formulary decisions
  • Medicare: 1-800-MEDICARE (1-800-633-4227)
  • Call the National Benefit Integrity Medicare Drug Integrity Contract (NBI MEDIC) at
    1-877-7SafeRx (877-772-3379) to report complaints concerning Medicare Parts C or D.
  • Call the Office of Inspector General (OIG) at 1-800-HHS-TIPS (1-800-447-8477).
    TTY: 1-800-377-4950
  • File a report online on the OIG website at: https://oig.hhs.gov/fraud/report-fraud/index.asp