Fight Fraud, Waste & Abuse

Definitions

Fraud: When someone makes a false statement, false claim or false representation to UCare where the person knows or should reasonably know the statement, claim or representation is false, and where the statement, claim or representation could result in an unauthorized benefit to the person or some other person.

Waste: Any over-utilization of services and misuse of resources that is not cause by fraud or abuse.

Abuse: A pattern of practice that is inconsistent with sound fiscal, business or medical practices and either directly or indirectly results in unnecessary costs to UCare, or that fail to meet professionally recognized standards for health care; enrollee practices that result in unnecessary cost to UCare; substantial failure to provide medically necessary items and services that are required to be provided to an enrollee if the failure has adversely affected or has a substantial likelihood of adversely affecting the health of the enrollee.