AllCARE for Seniors is committed to eliminating fraud, waste, and abuse and maintaining a highly ethical environment throughout our organization.  All employees and contractors are responsible for conducting themselves in an ethical manner in accordance with our compliance program and for reporting any suspected fraud, waste, and abuse.

Fraud means purposeful deception for the purpose of getting something of value (such as increased reimbursement from the government).  Examples include enrolling fictitious individuals in a PACE program and pocketing the money provided.

Waste means the careless or needless expenditure of funds that result in connection with a Part D plan.  Examples include poor or inefficient record-keeping that results in increased costs to the government.

Abuse means any kind of behavior that is inconsistent with sound fiscal, business or medical practices and that directly or indirectly results in higher costs to the government.  Examples include issuing refills for a prescription that is not medically necessary.

Examples of Fraud, Waste, and Abuse

· Submitting false data to CMS for purposes of obtaining reimbursement (including reinsurance and LICS payments) for prescription drugs not dispensed or not provided as claimed, or other costs not incurred as claimed.

· Submitting data for prescription drug claims that are known not to be reasonable and medically necessary.

· Intentionally misrepresenting the type of drug that was actually dispensed (e.g., claiming that a brand-name drug was dispensed when in reality a generic was dispensed).

· Knowingly submitting data for prescription drugs dispensed to, or obtained by,  individuals not eligible for Medicare Part D.

For more information about the Fraud, Waste, and Abuse program, you may download and review the Fraud, Waste, and Abuse Compliance Plan.

How to Report Fraud, Waste, or Abuse

You may remain anonymous when filing a report or you may ask that your identity be kept confidential.  If you request that your identity remain confidential, your identity will only be disclosed to the individuals assigned to review your complaint.  Keep in mind that it may be more difficult to investigate the allegation if you do not identify yourself in your report, as it may be necessary to ask you for additional information.

AllCARE for Seniors offers several ways for employees to report allegation of fraud, waste, or abuse:

AllCARE for Seniors

is a Program of All-Inclusive Care for the Elderly (PACE)

PACE is a program of the Commonwealth of Virginia

& Appalachian Agency for Senior Citizens (AASC)

FWA (Fraud, Waste, Abuse)

AASC Newsletter Spring 2011 PDF