Fraud, Waste and Abuse

Fraud, waste and abuse in the nation’s Medicaid program are estimated to cost taxpayers billions of dollars every year. Vaya Health is responsible for detecting, preventing and monitoring against fraud, waste and abuse of public funds and ensuring all services delivered and claims paid by Vaya are in compliance with controlling authority and generally accepted accounting principles.

What is fraud?

Fraud is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law. Examples of provider fraud in the Medicaid program include:

  • Billing for services, treatment or assessments that are not provided, not medically necessary or that lack documentation
  • Committing medical identity theft
  • Altering and/or falsifying documentation
  • Double-billing, balance billing, upcoding or other inappropriate billing
  • Unbundling services
  • Billing for unreasonable or inflated hours
  • Falsifying credentials
  • Substituting generic drugs
  • Billing for more expensive procedures than were performed or unallowable expenditures
  • Soliciting or accepting kickbacks
  • Submitting false cost reports
  • Billing from a non-credentialed site or for services that the provider or staff are improperly or not licensed to perform

Read more: Vaya Health False Claims Act Notice

Each network provider is required to ensure that you do not employ or contract with excluded individuals or entities. You must screen against the OIG List of Excluded Individuals and Entities, available on the OIG’s Exclusion Website.

What is waste?

Waste is defined as the misuse, underutilization or overutilization of items or services. This could also be any other inappropriate or unnecessary billing, as well as medical practices that directly or indirectly add to healthcare costs. This also includes unwarranted or unexplained variations in care that result in no discernible differences in health or member outcomes.

What is abuse?

  • Abuse is defined as provider practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to the Medicaid program, reimbursement for services that are not medically necessary or those that fail to meet professionally recognized standards for healthcare. It also includes beneficiary practices that result in unnecessary costs to the Medicaid program. Examples include:
    • Overutilization of medical and healthcare services
    • Separate billing for care and services that are part of an all-inclusive procedure or included in the per diem rate
    • Billing for care and services that are provided by an unauthorized or unlicensed person
    • Failure to provide and maintain proper quality of care, appropriate care and services or medically necessary care and services within accepted medical standards for the community
    • Breach of the terms and conditions of contracts
    • Failure to comply with requirements of certification
    • Failure to comply with the provisions for submitting claims for payment
    • Failure to comply with controlling authority

What are my responsibilities as a provider?

All Vaya network providers must monitor and guard against potential fraud, waste and abuse and must take immediate action to address and report any suspected incidents.

Report by phone or online

Network providers are required to establish a system or mechanism for employees, contractors and individuals receiving services to report potential fraud, waste or abuse. Network providers must also establish a system to report potential violations of anti-fraud laws, including, but not limited to, the FCA and anti-kickback statutes.

You must also ensure that your employees, contractors and individuals receiving services are aware of the following mechanisms to report potential fraud, waste, abuse or violations of the anti-fraud laws directly to Vaya or other oversight authorities:

  • Call Vaya’s 24/7 Confidential Compliance (Fraud and Abuse) Hotline at 1-866-916-4255 (allows for anonymous reporting)
  • Report online at (allows for anonymous reporting)
  • Call the N.C. Medicaid Fraud, Waste and Program Abuse Tip-Line at 1-877-DMA-TIP1 (1-877-362-8471)
  • Call the Office of Inspector General’s (OIG) National Fraud Hotline at 1-800-HHS-TIPS (1-800-447-8477) or report to the OIG online

Establish and implement a robust compliance program

The Patient Protection and Affordable Care Act requires all healthcare providers to establish and implement a compliance program. You must develop a formal compliance plan that includes procedures designed to guard against fraud and abuse. For more information and guidance about your compliance responsibilities as a healthcare provider who accepts public funding, please refer to the U.S. Health and Human Services’ Office of Inspector General Compliance Resources Portal.

Comply with Vaya program integrity audits and investigations

Vaya’s Special Investigations Unit conducts announced and unannounced audits and investigations of Medicaid and non-Medicaid paid claims to identify program abuse, waste and overpayment(s). It is your responsibility to cooperate with us during these audits and investigations.

Conduct self-audits

In addition to reporting potential fraud, waste and abuse violations, providers must conduct self-audits no less than annually (or more often in response to identification of questionable billing practices or staff ineligibility for billing) per your contract with Vaya. In accordance with federal law, you must return any overpayment you identify within 60 days of identification and notify Vaya of the reason for overpayment in writing.

For more information on conducting your self-audit, please refer to our Provider Self-Audit Protocol for Paid Claims Audits and Provider Self-Audit Overpayment Summary. This is an Excel workbook. Please click here to download.